A nurse is teaching a client who has a new prescription for tetracycline.
Which of the following information should the nurse include in the teaching?

Choice A rationale

Documenting a summary of data at the change of shift is a critical component of interprofessional communication, ensuring continuity of care. However, initial charting should be done promptly after data collection to maintain accuracy and prevent errors. Delaying documentation can lead to misinterpretation or omission of crucial information regarding the client's condition and needs. This practice ensures all members of the healthcare team are informed.

Choice B rationale

Noting whether a client has a living will is a fundamental ethical and legal obligation. This advance directive provides a written expression of a client’s wishes regarding medical treatment, which must be respected and documented in the medical record. It guides the healthcare team's decisions and ensures that the client's autonomy and right to self-determination are upheld.

Choice C rationale

Evaluation is the final step of the nursing process, following assessment, diagnosis, planning, and implementation. The nurse must first collect objective and subjective data, then analyze it before determining an appropriate plan of care. Beginning with an evaluation would bypass the essential steps of data collection and analysis, leading to an inaccurate or unsafe plan of care.

Choice D rationale

While assistive personnel can collect vital signs, the nurse is professionally and legally responsible for the data's accuracy and interpretation. The nurse must verify the data, analyze trends, and ensure it is documented accurately and promptly. The nurse is ultimately accountable for any actions taken based on this data, making proper documentation and validation essential.

Choice A rationale

A tympanogram is a diagnostic test that measures the movement of the eardrum in response to changes in air pressure in the ear canal. It is used to assess the function of the middle ear and is not a part of the Weber's test. The Weber's test is a gross screening tool for hearing acuity that uses a vibrating tuning fork to compare bone conduction in both ears, not to evaluate middle ear function.

Choice B rationale

The Weber's test is a simple screening tool to detect unilateral hearing loss. The nurse places a vibrating tuning fork on the midline of the child's head, such as the forehead or the top of the head. The sound is transmitted through the skull bones to the inner ears. The child is asked where the sound is heard best—in the left ear, right ear, or equally in both. This assesses bone conduction.

Choice C rationale

The Weber's test evaluates whether the sound is heard equally in both ears or lateralizes to one ear, indicating a potential conductive or sensorineural hearing loss. It does not measure the duration of sound perception. Measuring the amount of time a client can hear the sound after the tuning fork is placed on the mastoid bone is part of the Rinne test, a different component of hearing assessment, which compares bone and air conduction.

Choice D rationale

Holding a vibrating tuning fork 1 to 2 cm from the ear canal is a procedure used for the Rinne test, not the Weber's test. The Rinne test compares air conduction to bone conduction. The vibrating tuning fork is placed first on the mastoid bone (bone conduction) and then near the ear canal (air conduction). This is used to distinguish between conductive and sensorineural hearing loss. *.