A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

"Stand with your feet together and your arms at your sides.”

"After I place the tuning fork, tell me when you no longer hear the sound.”

"I'm going to stroke the lateral side of the bottom of your foot.”

"Touch each fingertip as quickly as possible with your thumb.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Stand with your feet together and your arms at your sides."

Choice A rationale:

This statement is correct. The nurse should instruct the client to stand with their feet together and their arms at their sides for a Romberg test. This position helps to assess the client's ability to maintain balance with minimal sensory input, evaluating their proprioception and vestibular function.

Choice B rationale:

The instruction about the tuning fork is unrelated to the Romberg test. The tuning fork is commonly used to assess hearing and vibratory sensations, not balance.

Choice C rationale:

This statement is unrelated to the Romberg test. Mentioning the lateral side of the foot suggests a neurological examination related to assessing reflexes, such as the Babinski reflex.

Choice D rationale:

This instruction pertains to a different test known as the "finger-to-nose" test, which is used to assess coordination, not balance.

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Correct Answer is B

Explanation

The correct answer is choice B: A thready pulse.

Choice A rationale:

BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.

Choice B rationale:

A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.

Choice C rationale:

Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.

Choice D rationale:

Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.

A. Eggs. B. Latex. C. Seafood. D. Bee stings.

Correct Answer is B

Explanation

The correct answer is: B. Latex.

Choice A reason: Allergy to eggs is primarily a concern when it comes to vaccinations, such as the influenza vaccine, which may contain egg protein. In the context of IV therapy, egg allergies are not typically associated with direct contraindications or precautions. However, it’s important to note that some medications or vaccines may contain egg proteins, which could be relevant in certain medical procedures, but not usually in standard IV therapy.

Choice B reason: Latex allergies are particularly relevant in a hospital setting where latex is commonly found in various medical supplies, including gloves, catheters, and IV tubing. A latex allergy can cause severe reactions, including anaphylaxis, which is a life-threatening condition. Therefore, it is crucial for healthcare providers to be aware of a patient’s latex allergy to avoid exposure during medical procedures, including IV therapy.

Choice C reason: Seafood allergies are generally related to the ingestion of seafood and do not typically pose a risk in the context of IV therapy. The concern about iodine in contrast media, which is sometimes mistakenly linked to seafood allergies, is not relevant to standard IV therapy solutions.

Choice D reason: Bee sting allergies are significant when a patient is exposed to bee venom, which can cause anaphylaxis. In the context of IV therapy, a bee sting allergy is not typically a concern unless the therapy involves venom immunotherapy or the patient has had a recent bee sting that might complicate their medical condition.

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A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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