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The client is undergoing a tuning fork test to assess for hearing conduction. The nurse performs a Rinne test. How will this test be performed?

Have the client close their eyes, lightly rub fingers together 12 inches away from the ear, and have the client identify which side the sound is heard.

First, place the tuning fork on the mastoid process behind the ear. When the client states the sound is no longer heard, place the tuning fork beside the ear.

Strike the tuning fork and place it in the center of the skull.

Stand three feet away and have the client repeat back what you have whispered.

Answer and Explanation

The Correct Answer is B

In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.

Choice A is incorrect because it describes the Weber test, not the Rinne test.

Choice C is incorrect because it is not a standard hearing test.

Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.

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Correct Answer is B

Explanation

Sips of fluid may be increased if tolerated. After a barium enema, the client may be allowed to increase fluid intake to help eliminate the barium and prevent constipation.

Option A: The client will maintain a low-residue diet is not a correct answer as it is not necessary after a barium enema.

Option C: An enema will be used to clear the bowel is not a correct answer as the barium enema is itself a type of enema used to visualize the colon.

Option D: The stools may be white or clay-colored is not a correct answer as it is a potential side effect of barium use, not an instruction to the client.

A. Tissue hypoxia. B. Cardiac failure. C. Hypovolemia. D. Infection.

Correct Answer is C

Explanation

Hypovolemia. Following a serious thermal burn, the nurse takes action to prevent hypovolemia, which can result from fluid loss due to the burn. Hypovolemia can lead to hypoperfusion of vital organs, including the kidneys, and can cause acute renal failure. Preventing hypovolemia is critical to preventing other complications such as tissue hypoxia, cardiac failure, and infection.

A. Tissue hypoxia and cardiac failure are consequences of hypovolemia due to decreased blood flow to organs.

D. Infection is not the immediate complication to prevent but is a potential complication following burn injury.

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The client is undergoing a tuning fork test to assess for hearing conduction. The nurse performs a Rinne test. How will this test be performed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing instruction is correct to provide the client following a barium enema?

Correct Answer is B

Explanation

Following a serious thermal burn, which complication will the nurse take action to prevent first?

Correct Answer is C

Explanation

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