A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take?

Pull the auricle upward and outward to straighten the ear canal.

Pull the auricle down and back to straighten the ear canal.

Sit the child up to insert the cotton ball into the innermost ear canal.

Sit the child up for 2 to 3 minutes after instilling drops in the ear canal.

Answer and Explanation

The Correct Answer is B

A: Pulling the auricle upward and outward is the correct technique for adults and children over 3 years old, not for a 2-year-old child.

B: Pulling the auricle down and back is the correct technique for straightening the ear canal in children under 3 years old. This allows for proper administration of the eardrops.

C: Sitting the child up to insert a cotton ball into the innermost ear canal is not appropriate. Cotton balls should not be inserted deeply into the ear canal.

D: Sitting the child up for 2 to 3 minutes after instilling drops is not necessary. The child should remain in a position that allows the drops to stay in the ear canal for the prescribed time.

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Correct Answer is D

Explanation

A: Blood pressure of 178/90 mm Hg indicates hypertension, not dehydration. Dehydration typically leads to low blood pressure due to reduced blood volume.

B: Jugular vein distention is associated with fluid overload or heart failure, not dehydration. Dehydration usually results in flat neck veins.

C: A heart rate of 50 beats per minute is bradycardia and is not typically associated with dehydration. Dehydration often causes an increased heart rate (tachycardia) as the body tries to maintain adequate circulation.

D: Skin tenting present is a classic sign of dehydration. When the skin is pinched and does not return to its normal position quickly, it indicates a lack of fluid in the tissues.

A. Petechiae B. Blood pressure C. Nausea D. Cyanosis

Correct Answer is C

Explanation

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

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A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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