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.
Hold an activated tuning fork against the client's mastoid process.
Whisper a series of words softly into one ear.
Place an activated tuning fork in the middle of the client's forehead.
The Correct Answer is D
Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Cleansing visibly fecal-soiled hands with alcohol-based hand rub is a possible source of infection because alcohol-based hand rubs are not effective against Clostridium difficile spores. The nurse should wash his or her hands with soap and water for at least 15 seconds after contact with fecal material or surfaces contaminated with feces.
Correct Answer is A
Explanation
When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.
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