A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Clean the hearing aid with isopropyl alcohol.
- B. Turn the hearing aid off for 5 minutes.
- C. Soak the hearing aid in warm water.
- D. Decrease the volume on the hearing aid.
Correct Answer: D
Rationale: Lowering volume addresses feedback, a common cause of whistling.
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A nurse is assisting in the care of a client who has pneumonia in the medical unit. Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)
- A. Take antibiotics for 10 days.
- B. Ensure the oxygen delivery system is at least 8 feet from any heat source.
- C. Decrease the steroid dose each day.
- D. Take antibiotic medication with or without food.
- E. Adjust the oxygen flow rate as needed to ease breathing.
- F. Take steroid medication in the morning.
Correct Answer: A,B,D,F
Rationale: A: Ensures full treatment course. B: Reduces fire hazard. D: Flexibility aids compliance. F: Morning dosing minimizes sleep disruption.
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Review the client's photograph in the medical record.
- B. Request an assistive personnel to identify the client.
- C. Ask the client to state their room number.
- D. Have the client state their phone number.
Correct Answer: A
Rationale: A photograph ensures accurate identification, critical for a client with dementia unable to self-identify.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an employer for a pre-employment screening.
- B. To a family member when the client is not available.
- C. To a medical interpreter service on behalf of a client.
- D. To an insurance agency in regard to a life insurance policy.
Correct Answer: C
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care, ensuring accurate communication.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Remove 45 mL of urine from the catheter with a syringe.
- C. Clamp the catheter tubing below the needleless port.
- D. Clamp the catheter tubing for 60 min.
Correct Answer: C
Rationale: Clamping below the port ensures a fresh, uncontaminated sample.
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