A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
Rephrase statements the client does not hear.
Determine if the client uses hearing aids.
Speak using his usual tone of voice and directly in front of the client.
Use hand gestures to communicate.
The Correct Answer is B
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
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Correct Answer is B
Explanation
Choice A rationale
Administering an IM injection does not typically require a gown as personal protective equipment unless there is a risk of exposure to blood or body fluids.
Choice B rationale
Completing a dressing change requires a gown to protect against potential exposure to blood or body fluids.
Choice C rationale
Administering an intermittent IV bolus medication does not typically require a gown unless there is a risk of exposure to blood or body fluids.
Choice D rationale
Talking to the client at the bedside does not require a gown as there is no risk of exposure to blood or body fluids.
Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect. While the tubes are designed to allow air to enter the middle ear and prevent fluid buildup, water can still enter through the tubes and potentially cause infections or other complications. Therefore, it is important to take precautions to keep water out of the ears, especially during activities like swimming or bathing.
Choice B rationale
This statement is incorrect. Tympanostomy tubes are not designed to be removed every night. They are small tubes inserted into the eardrum to allow air to enter the middle ear and prevent fluid buildup. They remain in place until they naturally fall out on their own, which typically happens within 6 to 12 months.
Choice C rationale
This statement is incorrect. The tubes do not need to be replaced every 2 years. Tympanostomy tubes usually fall out on their own within 6 to 12 months. If they do not fall out naturally, a healthcare provider may need to remove them. However, routine replacement every 2 years is not necessary.
Choice D rationale
This statement is correct. Tympanostomy tubes are designed to fall out on their own, usually within 6 to 12 months after insertion. This natural process allows the eardrum to heal without the need for additional surgical intervention.