A nurse is providing information to a client immediately before his scheduled Romberg test.

Which of the following statements should the nurse make?

"You will be standing with your feet 1 foot apart."

"You will place and hold your hands on your hips."

"I will be standing across the room from you to evaluate your sense of balance."

"I will be checking you once with your eyes open and once with them closed."

Answer and Explanation

The Correct Answer is D

A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.

B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.

C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.

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Correct Answer is D

Explanation

Choice A rationale:

Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.

Choice B rationale:

Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.

Choice C rationale:

Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.

Choice D rationale:

Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.

A. The nurse places the client on airborne precautions. B. The nurse has the client wear a mask for transport to radiology. C. The nurse wears an N95 respirator when performing client care. D. The nurse ensures the client's room maintains a positive airflow.

Correct Answer is D

Explanation

Choice A rationale:

Placing the client on airborne precautions for measles is the appropriate action. Measles is highly contagious and spreads through respiratory droplets. Airborne precautions, including wearing a mask, are essential to prevent the transmission of the virus to others. This action is in line with infection control protocols and ensures the safety of both healthcare providers and other patients.

Choice B rationale:

Having the client wear a mask for transport to radiology is a necessary precaution to prevent the spread of measles to others in the healthcare facility. It helps contain respiratory droplets and reduces the risk of transmission. This action aligns with infection control guidelines and is appropriate in this context.

Choice C rationale:

Wearing an N95 respirator when caring for a client with measles is necessary to protect healthcare providers from inhaling infectious particles. Measles is highly contagious, and airborne precautions, including the use of appropriate respiratory protection, are crucial. This action demonstrates the nurse's understanding of infection control measures.

Choice D rationale:

Ensuring the client's room maintains a positive airflow is wrong in anairborne infection isolation room. Negativeairflow helps prevent the contaminated air from flowing out of the room and spreading the infection to other areas of the healthcare facility. This action is consistent with the recommended infection control practices for airborne diseases.

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A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

Nursing Test Bank

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A nurse is providing information to a client immediately before his scheduled Romberg test.

Which of the following statements should the nurse make?