NCLEX-PN
NCLEX Questions on Sensory Perception Questions
Extract:
Question 1 of 5
During an assessment, the nurse covers the client's right eye and then observes a shift in the client's gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?
Correct Answer: D
Rationale: Covering and then uncovering the client's eye and then observing for a shift in the client's gaze is the cover-uncover test used to detect weakness in the extraocular muscles. Lens opacity is detected by direct observation. Stroking the eyelashes will evoke the blink reflex. The intraocular pressure is measured by tonometry.
Question 2 of 5
Which referral is most important for the nurse to implement for the client with permanent hearing loss?
Correct Answer: A
Rationale: Aural rehabilitation addresses communication strategies and hearing aids, critical for permanent hearing loss. Speech therapy, social work, and vocational rehab are secondary.
Question 3 of 5
The client has an hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement?
Correct Answer: C
Rationale: Warm compresses are applied to promote drainage of the hordeolum. Patching is not indicated, miotic drops treat glaucoma, and IV antibiotics are unnecessary as topical antibiotics are used.
Question 4 of 5
The client with severe otitis media and mastoiditis is prescribed levofloxacin IV, 250 mg every 12 hours. The medication is diluted in 100 mL of NS. To deliver the antibiotic in 30 minutes, the nurse must infuse the solution at a rate of how many mL per hour?
Correct Answer: A
Rationale: The rate of IV infusion is calculated as follows: 100 mL over 30 minutes equals X mL over 60 minutes. Thus, 100/30 = X/60, so X = (100 × 60) / 30 = 200 mL/hr.
Question 5 of 5
A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to:
Correct Answer: A
Rationale: Symptoms suggest autonomic dysreflexia, often triggered by bladder distention, requiring immediate assessment and intervention.