behind the ear hearing aid instructions

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. What are the instructions for a behind-the-ear hearing aid?

A. Remove before sleeping
B. Remove before shower
C. Keep on during all activities
D. Replace every week

Correct answer: B

Rationale: The correct answer is to remove a behind-the-ear hearing aid before showering to prevent water damage. Choice A is incorrect because it is safe to wear the hearing aid while sleeping as it does not pose a risk of damage. Choice C is incorrect because it is advisable to remove the hearing aid during certain activities to prevent damage or loss. Choice D is incorrect as hearing aids do not need to be replaced weekly unless there is an issue with the device.

2. When working with a client who does not speak the same language, which of the following actions should the nurse take?

A. Speak directly to the interpreter
B. Use family members to translate
C. Speak directly to the patient
D. Use medical jargon

Correct answer: C

Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.

3. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

A. Immediately do a complete head-to-toe neurological assessment.
B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
C. Place a blanket over the feet.
D. Remove the restraint.

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

4. A nurse is preparing to administer ampicillin 500 mg IV bolus every 6 hours. Available is ampicillin 500 mg in 50 mL dextrose 5% in water (D5W) to infuse over 20 minutes. The nurse should set the IV pump to deliver how many mL/hr?

A. 100 mL/hr
B. 150 mL/hr
C. 200 mL/hr
D. 250 mL/hr

Correct answer: B

Rationale: To infuse 50 mL over 20 minutes, the pump should be set to 150 mL/hr. This calculation ensures the correct rate for the infusion of the medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the given information.

5. What is the primary intervention for a client diagnosed with delirium?

A. Provide a quiet and calm environment to minimize confusion
B. Administer medication to reverse the symptoms of delirium
C. Provide opportunities for social interaction to reduce isolation
D. Encourage the client to remain physically active

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and calm environment to minimize confusion. For clients diagnosed with delirium, creating a tranquil setting can help reduce agitation and disorientation. This intervention aims to decrease stimuli that may exacerbate symptoms. Administering medication (choice B) is not the primary intervention for delirium; it is usually reserved for specific underlying causes. While social interaction (choice C) and physical activity (choice D) are beneficial for overall well-being, they are not the primary interventions for managing delirium.