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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Verifying the medication against the prescription and medication label is a correct and essential step in ensuring the right medication is given to the right patient.
B: Documenting medication administration prior to administering is incorrect and can lead to errors. Documentation should occur immediately after the medication is given to ensure accuracy and prevent discrepancies.
C: Scanning the bar code on the medication administration record and the client’s arm band is a correct practice that helps verify the patient’s identity and the medication being administered.
D: Checking the provider’s orders and confirming the dosage is a necessary step to ensure the correct medication and dose are given. This action is part of safe medication administration practices.
Correct Answer is C
Explanation
A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.
B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.
C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.
D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.
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