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A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
- A. I will wear earphones during this test
- B. A small probe is placed inside my ear
- C. A tuning fork is placed on my head
- D. Small electrodes are placed on my scalp
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is first placed against the client's mastoid bone behind the ear and then moved near the ear canal. The client should hear the sound louder when the fork is near the ear if the test is normal. Choice A is incorrect because earphones are not used in the Rinne test. Choice B is incorrect as a probe is not inserted into the ear. Choice D is incorrect as electrodes are not part of the Rinne test. Placing a tuning fork on the head is the correct step in performing the Rinne test to assess hearing conduction.
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A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?
- A. Crushing the medication would release all the medication at once, rather than over time
- B. Crushing the medication might cause you to have a stomachache or indigestion
- C. Crushing the medication is a good idea, and I can mix in some ice cream for you
- D. Crushing is unsafe, as it destroys the ingredients in the medication
Correct Answer: B
Rationale: The correct answer is B. Crushing enteric-coated aspirin can lead to stomachache or indigestion because the coating is designed to protect the stomach lining from irritation. By crushing it, the medication can be released too quickly, causing irritation. Choice A is incorrect because it focuses on the timing of medication release rather than the potential harm of crushing it. Choice C is incorrect as adding ice cream does not address the issue of medication safety. Choice D is incorrect as it does not provide a specific reason why crushing is unsafe.
A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
A nurse is preparing to administer digoxin 5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 10
Rationale: The correct answer is 10 tablets. To calculate, you divide the total dose needed (5 mg) by the dose per tablet (0.5 mg). 5 mg ÷ 0.5 mg = 10 tablets. The nurse should administer 10 tablets of digoxin to achieve the desired 5 mg dose. Other choices are incorrect because they do not result in the correct dosage amount required for the client.
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?
- A. The client reports dizziness when ambulating to the bathroom
- B. The client reports having trouble sleeping the previous night
- C. The client ate 60% of their breakfast
- D. The client has a urine output of 400 mL for the past 8 hr
Correct Answer: A
Rationale: The correct answer is A. Dizziness when ambulating can be a sign of orthostatic hypotension, a potential side effect of antihypertensive medication. The nurse should further assess for signs of hypotension before administering the medication. Choices B, C, and D are less relevant to antihypertensive medication administration. Reporting trouble sleeping, eating 60% of breakfast, and having a urine output of 400 mL are not direct contraindications for administering antihypertensive medication.
A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?
- A. Describe the steps of walking with crutches for the client
- B. Encourage the client to ask questions about walking with crutches
- C. Show the client a video on walking with crutches
- D. Ask the client to demonstrate walking with crutches
Correct Answer: D
Rationale: The correct answer is D: Ask the client to demonstrate walking with crutches. This intervention engages the psychomotor domain of learning by requiring the client to physically demonstrate the skill being taught. This hands-on approach helps the client develop muscle memory and coordination needed to effectively use crutches.
A, B, and C do not directly involve physical action or demonstration by the client. A describes verbal instruction, B encourages questioning and discussion, and C involves visual learning through a video. While these interventions are valuable in the learning process, they do not specifically target the physical practice of using crutches.
In summary, option D is the correct choice as it actively engages the client in practicing the skill, aligning with the psychomotor domain of learning.