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.

Answer and Explanation

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

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Correct Answer is C

Explanation

A. Use an 18-gauge, 1-inch needle to administer the medication:
This is incorrect because an 18-gauge needle is too large and not appropriate for subcutaneous injections like heparin. A smaller gauge needle, such as 25- to 27-gauge, and a shorter length (⅜ to ⅝ inch) is recommended for subcutaneous injections.

B. Massage the injection site after withdrawing the needle:
This is incorrect because massaging the injection site after administering heparin can increase the risk of bruising and hematoma formation. Heparin is an anticoagulant, and gentle handling of the injection site is crucial.

C. Inject 5.1 cm (2 in) away from the umbilicus:
This is correct. Heparin is administered subcutaneously, typically in the abdomen, avoiding areas near the umbilicus or scars. Injecting at least 2 inches away from the umbilicus ensures the medication is delivered to appropriate subcutaneous tissue and minimizes complications.

D. Expel air bubble before injecting medication:
This is incorrect because the air bubble in prefilled heparin syringes should not be expelled. The air bubble helps ensure the full dose is administered and reduces the risk of medication leakage.

A. Cooked vegetables B. Bananas C. Pudding D. Yogurt with fruit

Correct Answer is C

Explanation

A. Cooked vegetables are not typically included in a full liquid diet as they contain solid parts.
B. Bananas are not part of a full liquid diet because they are solid foods.
C. Pudding is a suitable selection for a full liquid diet as it's a smooth, creamy food that's easy to swallow.
D. Yogurt with fruit might contain solid parts, which aren't recommended in a full liquid diet.

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A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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