Nokea
A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is most appropriate?
- A. Assess for signs of dehydration.
- B. Review the client's medication list.
- C. Monitor for signs of hearing loss.
- D. Consult with the healthcare provider.
Correct Answer: D
Rationale: Elevated blood urea nitrogen (BUN) and creatinine levels suggest renal impairment, which can affect drug metabolism and increase the risk of ototoxicity from certain medications. Consulting with the healthcare provider is the most appropriate action to ensure safe care. The other options may be relevant but are not the priority.
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The student nurse is performing a Weber tuning fork test. What technique is most appropriate?
- A. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
- B. Placing the vibrating fork in the middle of the clients head
- C. Placing the vibrating fork in the middle of the clients head
- D. Tapping the vibrating tuning fork against the bridge of the nose
Correct Answer: B
Rationale: The Weber tuning fork test involves placing the vibrating tuning fork in the middle of the client's head and asking in which ear the client hears the vibrations loudest. The other techniques are incorrect.
A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.)
- A. Be careful not to drop the hearing aid when handling.
- B. Soak the hearing aid in hot water for 20 minutes.
- C. Turn the hearing aid off when the client goes to bed.
- D. Use a toothpick to clean debris from the device.
- E. Wash the device with soap and a small amount of warm water.
Correct Answer: A,C,D,E
Rationale: All these actions except soaking the hearing aid in hot water are proper instructions for the nurse to give to the UAP. While some water is used to clean the hearing aid, excessive wetting should be avoided.
A client with labyrinthitis is prescribed antibiotics. What instruction is most important for the nurse to include?
- A. Immediately report headache or stiff neck.
- B. Keep all follow-up appointments.
- C. Take the antibiotics with a full glass of water.
- D. Take the antibiotic on an empty stomach.
Correct Answer: A
Rationale: Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.
During ear irrigation, what action should the nurse take if the client becomes nauseated?
- A. Continue the procedure slowly.
- B. Stop the procedure immediately.
- C. Administer an antiemetic medication.
- D. Encourage the client to breathe deeply.
Correct Answer: B
Rationale: During ear irrigation, if the client becomes nauseated, the nurse should stop the procedure immediately to prevent further discomfort or complications. The other options are not appropriate in this context.
A client has Ménière's disease with frequent attacks. About what drugs does the nurse plan to teach the client? (Select all that apply.)
- A. Broad-spectrum antibiotics
- B. Chlorpromazine hydrochloride (Thorazine)
- C. Diphenhydramine (Benadryl)
- D. Meclizine (Antivert)
- E. Nonsteroidal anti-inflammatory drug (NSAID)
Correct Answer: B,C,D
Rationale: Drugs such as chlorpromazine, diphenhydramine, and meclizine can all be used to treat Ménière's disease. Antibiotics and NSAIDs are not used.