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.
Place an activated tuning fork in the middle of the client's forehead.
Hold an activated tuning fork against the client's mastoid process.
Whisper a series of words softly into one ear.
The Correct Answer is B
A. Delivering a series of high-pitched sounds at random intervals is not related to the Weber's test.
B. Weber's test is performed by striking the tuning fork and placing it against the middle of the forehead. Ask the patient if the tone is equal in both ears. Diminution in the affected ear indicates sensorineural hearing loss.
C. Placing an activated tuning fork on the client's mastoid process is not part of the Weber's test.
D. Whispering a series of words softly into one ear is unrelated to the Weber's test; it's a test for assessing auditory acuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sterile gloves, not clean gloves, should be worn when cleaning the inner cannula to reduce the risk of introducing infection into the tracheostomy site, which is a direct pathway to the airway.
B. Placing gauze pads under the flanges of the tracheostomy tube isn't a standard practice for tracheostomy care.
C. Cleansing the skin around the stoma with full-strength hydrogen peroxide can be too harsh and irritating to the skin.
D. Using a tracheostomy collar with hook-and-loop fasteners is a safe and effective way to secure the tracheostomy tube, ensuring it remains in place while minimizing the risk of skin breakdown and irritation. This method also allows for easier adjustment and replacement of the collar.
Correct Answer is B
Explanation
A. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces on the skin.
B. Elevating the heels reduces the pressure on the skin and improves blood circulation.
C. Raising the head of the bed to a 60° angle doesn't directly address pressure injury prevention and might even increase pressure on certain areas.
D. Repositioning the client every 4 hours is not frequent enough to prevent pressure injuries.
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