A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Deliver a series of high-pitched sounds at random intervals.

Place an activated tuning fork in the middle of the client's forehead.

Hold an activated tuning fork against the client's mastoid process.

Whisper a series of words softly into one ear.

Answer and Explanation

The Correct Answer is B

A.   Delivering a series of high-pitched sounds at random intervals is not related to the Weber's test.
B.   Weber's test is performed by striking the tuning fork and placing it against the middle of the forehead. Ask the patient if the tone is equal in both ears. Diminution in the affected ear indicates sensorineural hearing loss.
C.   Placing an activated tuning fork on the client's mastoid process is not part of the Weber's test.
D.   Whispering a series of words softly into one ear is unrelated to the Weber's test; it's a test for assessing auditory acuity.

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Correct Answer is D

Explanation

A. Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.
B. A quick-release knot is not typically used for securing tracheostomy ties for safety reasons.
C. Extending the client's neck while securing the ties could cause discomfort and is not necessary.
D. This is the safest method to prevent accidental dislodgement of the tracheostomy tube. By securing the new ties first, the tracheostomy tube remains in place, reducing the risk of complications.

A. "The scale measures six elements." B. "The client's age is part of the measurement." C. "The higher the score, the higher the pressure injury risk." D. "Each element has a range from one to five points."

Correct Answer is A

Explanation

A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.

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A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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