A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Stand directly in front of the client.

Rephrase statements the client does not hear.

Speak using his usual tone of voice.

Determine if the client uses hearing aids.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because standing directly in front of the client is not the priority action by the nurse when admitting a client who has a partial hearing loss. Standing directly in front of the client can enhance communication, but it is not as important as assessing the client's hearing status and needs.

Choice B Reason: This is incorrect because rephrasing statements the client does not hear is not the priority action by the nurse when admitting a client who has a partial hearing loss. Rephrasing statements can improve understanding, but it is not as essential as evaluating the client's hearing level and preferences.

Choice C Reason: This is incorrect because speaking using his usual tone of voice is not the priority action by the nurse when admitting a client who has a partial hearing loss. Speaking using his usual tone of voice may or may not be appropriate, depending on the client's hearing ability and comfort. The nurse should adjust his tone of voice based on the client's feedback and response.

Choice D Reason: This is the correct choice because determining if the client uses hearing aids is the priority action by the nurse when admitting a client who has a partial hearing loss. Hearing aids are devices that amplify sound and improve hearing for people with hearing loss. The nurse should determine if the client uses hearing aids, and if so, check their function, fit, and battery life. The nurse should also ask about any other assistive devices or strategies that the client uses to communicate effectively.

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Free Nursing Study Resources

Correct Answer is ["2600"]

Explanation

The total fluid prescribed is 5,200 mL over 24 hours. We need to calculate how much fluid the client will receive in the first 8 hours.

Step-by-Step Calculation:

Step 1: Determine how much fluid is given in the first 8 hours. The rule is that half of the total fluid is administered in the first 8 hours.

Total fluid = 5,200 mL.
Fluid for the first 8 hours = Total fluid ÷ 2.

Write it out:
5,200 ÷ 2 = 2,600.

Result: 2,600 mL.

A. Turn off the lights and TV and close the door for privacy B. Use one wrist restraint to keep the client safe C. Ask the physician for a sedative D. Identify if there is a cause for the agitation

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.

Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.

Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.

Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.

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A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many milliliters of fluid will the client receive in the first 8 hours? Record your answer.

Correct Answer is ["2600"]

Explanation

Step-by-Step Calculation:

It is night time and a client who suffers from dementia is agitated and is having difficulty staying in his bed. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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