A nurse at a long-term care facility is assessing a client who just received hearing aids. Which of the following actions should indicate to the nurse that the client understands how to use the hearing aids? (Select all that apply.)
Cleanses the ear molds with isopropyl alcohol to remove cerumen
Turns off the hearing aids when not in use
Inspects the ear molds to determine the ear canal portion
Turns the volume all the way down before inserting the hearing aids
Ensures that the ears are not blocked with cerumen
Correct Answer : B,C,D,E
A. Cleanses the ear molds with isopropyl alcohol to remove cerumen: Alcohol is not recommended for cleaning hearing aids, as it can damage the device. A mild soap and water solution or a designated cleaning tool is preferable.
B. Turns off the hearing aids when not in use: Turning off hearing aids conserves battery life, which is a proper maintenance practice.
C. Inspects the ear molds to determine the ear canal portion: Properly positioning the hearing aids ensures correct use and comfort.
D. Turns the volume all the way down before inserting the hearing aids: This prevents a sudden loud noise that could startle the client and allows them to adjust to a comfortable volume after insertion.
E. Ensures that the ears are not blocked with cerumen: Blocked cerumen can interfere with hearing aid functionality, so this is an essential step.
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Correct Answer is B
Explanation
A. Prepare an incident report for risk management: While this is necessary, it’s not the priority action as it doesn’t directly address the immediate need for type and cross-matching.
B. Inform the provider of the delay in obtaining the type and cross-match: The nurse should inform the provider first to allow for any changes to the client's preoperative plan. Immediate notification is essential for any follow-up actions, as blood products might be required, or surgery could be rescheduled if the match is not completed.
C. Obtain the client's type and cross-match: This action would be appropriate if it had not already been ordered. Since the order exists, the provider should be informed of the delay first to guide further steps.
D. Document the incident in the client's medical record: Documentation is important but should occur after informing the provider and obtaining the blood work, as it does not directly address the current client care needs.
Correct Answer is A
Explanation
A. Postural hypotension: Postural hypotension (a drop-in blood pressure when moving to a standing position) is a common sign of extracellular fluid volume deficit due to decreased circulating blood volume.
B. Dependent edema: This occurs with fluid volume excess, not deficit, due to fluid accumulation in tissues.
C. Bradycardia: Fluid volume deficit often leads to tachycardia as the body compensates for low blood volume, rather than a slow heart rate.
D. Distended neck veins: Distended neck veins suggest fluid overload, not a fluid deficit.