A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take?
Place a vibrating tuning fork on the top of the client's head.
Move a vibrating tuning fork's prongs in front of the client's left or right ear canal.
Activate a tuning fork and place the prongs on the client's occipital area.
Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse.
The Correct Answer is B
A. Place a vibrating tuning fork on the top of the client's head: This describes the Weber test, which assesses lateralization of sound to determine conductive versus sensorineural hearing loss.
B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal: In the Rinne test, the nurse compares bone conduction and air conduction. After placing the fork on the mastoid bone, it is moved in front of the ear canal to test air conduction, which should normally be longer than bone conduction.
C. Activate a tuning fork and place the prongs on the client's occipital area: Placing the tuning fork on the occipital bone is not part of any standard hearing assessment test. It would not yield useful information about bone or air conduction.
D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse: This describes the whisper test, a screening tool for gross hearing acuity. It is not related to the Rinne test procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
Desired dose = 2 mg.
Available concentration = 5 mg/1 mL.
- Calculate the volume to administer in milliliters (mL).
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
= 2 mg / 5 mg/mL
= 0.4 mL.
Correct Answer is ["A","D","E"]
Explanation
A. Encourage client to consume foods with zinc: Zinc plays an important role in wound healing and immune function. Since this client has diabetes and an infected wound, zinc-rich foods can support tissue repair and recovery, making this prescription appropriate.
B. Apply ice pack to left foot for 30 min/hr: Ice is not appropriate for an infected wound because it can impair circulation and slow healing. Instead, treatment should focus on infection management, wound care, and improving blood flow.
C. Administer an oral antiviral medication: The client’s presentation is consistent with a bacterial infection, not a viral process. Purulent drainage, fever, and wound infection require antibacterial therapy, not antiviral medications.
D. Obtain a culture of the client's wound: Wound culture is necessary to identify the causative organism and guide antibiotic therapy. This is an important step in managing diabetic foot infections, which often involve resistant bacteria.
E. Administer tetanus toxoid injection: Since the wound occurred after stepping on glass or metal, there is a risk of tetanus exposure. Administering a tetanus booster is recommended if vaccination is not up to date or uncertain.
F. Apply transparent dressing over the client's wound: Transparent dressings are not suitable for infected wounds with drainage because they can trap moisture and bacteria. Instead, absorbent dressings should be used to promote healing.
G. Place client in airborne precautions: Airborne precautions are for illnesses such as tuberculosis or measles. A foot wound infection does not spread via airborne transmission, so this is unnecessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.