During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Follow up by having the client perform the Rinne test

Reposition the client supine to ensure safety.

Document successful completion of the assessment.

Facilitate a referral to a neurologist.

Answer and Explanation

The Correct Answer is C

Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["4 "]

Explanation

The nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL.

Step 1 is: Calculate the dose in mL using the formula: (Desired dose ÷ Available dose) × Volume.

Step 2 is: Substitute the given values into the formula: (40 mg ÷ 10 mg) × 1 mL = 4 mL. The nurse should administer 4 mL per dose.

A. Instruct the client on daily muscle stretching. B. Order a low-residual diet. C. Encourage the client to void every hour. D. Provide total assistance with all activities of daily living.

Correct Answer is A

Explanation

Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.

Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.

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During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL. How many mL should the nurse administer per dose? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

Correct Answer is ["4 "]

Explanation

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

Correct Answer is A

Explanation

A patient is being evaluated for hearing loss. The doctor is unable to examine the tympanic membrane due to a blockage caused by cerumen. What actions can the nurse take to allow for an examination?

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