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A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.
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The rate at which I.V. fluids are infused is based on the burn client's:
- A. I.V. and body surface area (BSA) burned.
- B. Total body weight and BSA burned.
- C. Total BSA and BSA burned.
- D. Height and weight and BSA burned.
Correct Answer: B
Rationale: The Parkland Formula uses total body weight and percentage of BSA burned to calculate fluid requirements, ensuring adequate resuscitation based on burn severity.
The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because:
- A. A 17G needle is used.
- B. A subarachnoid injection is made.
- C. A noncutting needle is used.
- D. A faster onset occurs.
Correct Answer: C
Rationale: Epidural anesthesia uses a noncutting needle, reducing dural puncture risk and thus lowering the incidence of spinal headache compared to spinal anesthesia.
The client has had hypertension for 20 years. The nurse should assess the client for?
- A. Renal insufficiency and failure.
- B. Valvular heart disease.
- C. Endocarditis.
- D. Peptic ulcer disease.
Correct Answer: A
Rationale: Long-standing hypertension damages kidneys, leading to renal insufficiency or failure, a common complication requiring assessment.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.
The nurse is caring for a client in critical condition requiring several medications. The nurse understands which route of administration would be recommended for this client?
- A. Subcutaneous (subQ)
- B. Intravenous (IV)
- C. Intramuscular (IM)
- D. Oral (PO)
Correct Answer: B
Rationale: IV administration provides rapid and reliable delivery for a client in critical condition.