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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I will limit the length of my bath to 30 minutes.": While shorter baths can prevent skin dryness, this does not directly relate to safety. The teaching focuses on reducing fall risks, so bath duration is less relevant to preventing injury.

B. "I will apply bath oil to the water to moisturize my skin.": Adding bath oil increases the slipperiness of the tub, significantly raising the risk of falls. This poses a safety hazard rather than promoting safe bathing.

C. "I will drain the tub after I get out.": Draining the tub after exiting is common practice but does not reduce fall risk during entry or exit. Safety measures should focus on preventing slips before and while leaving the tub.

D. "I will place a bathmat in front of the tub.": Using a bathmat provides traction on wet bathroom floors and reduces the likelihood of slipping when getting in or out of the tub. This demonstrates understanding of effective bathtub safety teaching.

A. Insert an indwelling urinary catheter. B. Use an alcohol-free barrier product. C. Reposition the client every 4 hr. D. Massage the skin over bony prominences.

Correct Answer is B

Explanation

A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.

C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

View Question and Answer

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

A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client about bathtub safety. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

Correct Answer is B

Explanation

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?

A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. Which of the following clients requires a priority referral?

A nurse is planning care for a client who has dysphagia and is at risk for aspiration. Which of the following referrals should the nurse make?

A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients?

A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?