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 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.
Correct Answer is D
Explanation
A: Having the client move in with a family member or close friend can provide emotional support and assistance with daily activities. However, it does not specifically address the safety needs related to hearing loss. While this option can be beneficial, it is not the most direct solution for ensuring the client’s safety in their home environment.
B: Encouraging the client to get a roommate can also provide companionship and assistance. However, like option A, it does not directly address the specific safety concerns associated with hearing loss. The presence of a roommate might help in emergencies, but it is not a guaranteed solution for all safety issues.
C: Increasing the sound on all alarms might seem like a logical step, but it is not effective for someone with full hearing loss. This approach does not ensure that the client will be alerted to emergencies, as they may not hear the alarms regardless of the volume.
D: Installing flashing lights for alarms is the most effective recommendation for a client with full hearing loss. Visual alarms can alert the client to emergencies such as fires or intruders, ensuring their safety. This solution directly addresses the client’s inability to hear auditory alarms and provides a reliable method for emergency alerts.
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