A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client received 0.45% sodium chloride IV at 500 mL/hr for 3 hr. then at 200 mL/hr for 3 hr., and then dextrose 5% in water at 75 mL/hr for 2 hr. What is the total volume the nurse should document for the client's IV fluid intake? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A. Holding a vibrating tuning fork 1 to 2 cm from the child's ears is not a part of the Weber's test procedure. The Weber's test involves assessing lateralization of sound in cases of unilateral hearing loss. Placing the tuning fork close to the ears may interfere with the accuracy of the test.
B. Measuring the amount of time the child can hear the sound is not relevant to the Weber's test. This action does not assess lateralization of sound but rather evaluates the duration of hearing.
C. Obtaining a tympanogram reading is not necessary before initiating the Weber's test. Tympanometry is a separate test used to assess the function of the middle ear, particularly the movement of the eardrum and the conduction bones.
D. Placing a vibrating tuning fork on the top of the child's head is the correct action for performing the Weber's test. During this test, the nurse activates a tuning fork and places it on the midline of the child's head or forehead. The child is asked if they hear the sound equally in both ears or if it is louder in one ear than the other. This helps determine if there is asymmetrical hearing loss.

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.