A school nurse is using Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.

Place a vibrating tuning fork on the top of the child's head.

Whisper a statement to the child from 0.6 m (2 feet) away.

Apply a pair of headphones securely over the child's ears

Answer and Explanation

The Correct Answer is B

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

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Correct Answer is D

Explanation

A. Fold the stockings at the top if they are too long – Folding the stockings can create a tourniquet effect, restricting circulation and increasing the risk of complications.

B. Remove the stockings every 24 hr – Antiembolitic stockings should be removed at least every 8 hr to assess skin integrity and circulation, not just once per day.

C. Massage the legs before applying the stockings – Massaging the legs is contraindicated in clients with DVT because it can dislodge a clot, leading to a pulmonary embolism.

D. Measure the legs with a tape measure to determine stocking size – This is the correct action because improper fit can reduce effectiveness or impair circulation. The nurse should measure the client’s legs and select the appropriate size for optimal compression.

A. A child who has acute epiglottitis and is drooling B. A child who has a urinary tract infection and bright red blood in her urine C. A child who has mononucleosis and reports severe fatigue D. A child who has Wilms' tumor and an abdominal mass

Correct Answer is A

Explanation

A. A child who has acute epiglottitis and is drooling – This is the priority because drooling, stridor, and respiratory distress suggest airway obstruction, which is life-threatening. Immediate intervention is required to secure the airway.

B. A child who has a urinary tract infection and bright red blood in her urine – Hematuria can be concerning but is not immediately life-threatening.

C. A child who has mononucleosis and reports severe fatigue – Fatigue is common with mononucleosis but does not require immediate intervention.

D. A child who has Wilms' tumor and an abdominal mass – While Wilms' tumor is serious, it does not present an immediate airway or hemodynamic emergency.

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A school nurse is using Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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