The client is undergoing a tuning fork test to assess for hearing conduction. The nurse performs a Rinne test. How will this test be performed?
Have the client close their eyes, lightly rub fingers together 12 inches away from the ear, and have the client identify which side the sound is heard.
First, place the tuning fork on the mastoid process behind the ear. When the client states the sound is no longer heard, place the tuning fork beside the ear.
Strike the tuning fork and place it in the center of the skull.
Stand three feet away and have the client repeat back what you have whispered.
The Correct Answer is B
In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.
Choice A is incorrect because it describes the Weber test, not the Rinne test.
Choice C is incorrect because it is not a standard hearing test.
Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Provide the client with warm fluids. The shivering can occur due to the anesthesia, the effect of the surgery, or cold temperature in the operating room. The shivering increases the client's oxygen consumption and carbon dioxide production, which can cause hypoxia, hypercapnia, and acidosis. The nurse should provide warm fluids to prevent hypothermia and warm blankets to reduce shivering.
Option A, placing the client on a hypothermia blanket, is incorrect because it is used to lower body temperature, not raise it.
Option C, covering the client with a light blanket, is incorrect because it is not enough to keep the client warm.
Option D, ensuring that the room temperature is below 70°F, is incorrect because it is too cold for the client and can increase shivering.
Correct Answer is A
Explanation
Exposing the affected area to air. To maintain skin integrity, the nurse should advise the client to expose the affected area to air.
Barrier garments, such as liners and protective pants, can trap moisture and irritate the skin, which can lead to skin breakdown. Exposing the affected area to air can help keep the skin dry and prevent skin breakdown.
B is not the correct answer because the application of moisture sealant can help protect the skin and prevent skin breakdown.
C is not the correct answer because using an electric room deodorizer is not related to maintaining skin integrity.
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