A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Whisper a series of words softly into one ear.
Place an activated tuning fork in the middle of the client's forehead.
Deliver a series of high-pitched sounds at random intervals.
Hold an activated tuning fork against the client's mastoid process.
The Correct Answer is B
A. Whisper a series of words softly into one ear.
Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.
B. Place an activated tuning fork in the middle of the client's forehead.
Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.
C. Deliver a series of high-pitched sounds at random intervals.
Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.
D. Hold an activated tuning fork against the client's mastoid process.
Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Combining medications with the formula in the feeding bag:
This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.
B. Diluting each crushed medication with warm water:
While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.
C. Mixing the medications together in a single syringe:
This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.
D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:
Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.
Correct Answer is A
Explanation
A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.
B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.
C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.
D, Reposition the client every 4 hr.
Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.
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