A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?

Pull the client's pinna down and back to apply the solution.

Perform the procedure using sterile gloves.

Administer the irrigation solution at room temperature to the ear

Apply a stream of pressure as long as the client can tolerate.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Pull the client's pinna down and back to apply the solution.: Pulling the pinna down and back is the correct technique for infants and young children due to the angle of the ear canal. For adults, the pinna should be pulled up and back to straighten the ear canal. Using the incorrect direction can prevent proper visualization and reduce effectiveness of the irrigation.

B. Perform the procedure using sterile gloves.: Ear irrigation is a clean procedure, not a sterile one. The external ear canal is not a sterile environment, and using sterile gloves does not reduce infection risk. Clean gloves provide adequate protection while maintaining proper hygiene during cerumen removal.

C. Administer the irrigation solution at room temperature to the ear.: Using a solution at room temperature prevents stimulation of the vestibular system, which can cause dizziness, nausea, and vertigo. A temperature-neutral solution promotes client comfort and reduces physiologic irritation while effectively helping soften and remove cerumen.

D. Apply a stream of pressure as long as the client can tolerate.: Using forceful or prolonged pressure can damage the tympanic membrane or push cerumen deeper into the canal. Irrigation should be done gently, allowing the solution to flow along the canal wall and stopping immediately if the client reports pain or dizziness to avoid injury.

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Correct Answer is C

Explanation

Rationale:

A. Inform the transferring agency of the client's condition: While notifying the transferring facility may be part of documentation or reporting, it does not directly address suspicions of abuse. The priority is to gather accurate information from the client in a safe and confidential manner before reporting.

B. Notify risk management: Risk management may be involved in internal investigation processes, but contacting them is not the first step when abuse is suspected. Immediate priority is assessing the client’s safety and obtaining information about the injuries.

C. Privately interview the client about the injuries: Conducting a private, nonjudgmental interview allows the nurse to gather direct information about the cause of the injuries without influence or intimidation from others. This is a critical first step in identifying potential elder abuse, ensuring the client’s safety, and providing evidence for appropriate reporting.

D. Contact the family regarding the client's condition: Contacting family members before assessing the client can compromise the investigation, particularly if family members are potential perpetrators. Privacy and safety of the client must be prioritized before involving others.

A. Naloxone B. Acetaminophen C. Fentanyl D. Zolpidem

Correct Answer is C

Explanation

Rationale:

A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose. It does not provide pain relief and is not appropriate for managing acute exacerbations of chronic pain.

B. Acetaminophen: Acetaminophen is useful for mild to moderate pain but may be insufficient for an acute exacerbation of chronic pain, especially if the client has severe or breakthrough pain.

C. Fentanyl: Fentanyl is a potent opioid analgesic appropriate for managing severe acute pain or acute exacerbations of chronic pain. It acts rapidly to relieve pain and is often used in clients already tolerant to opioids.

D. Zolpidem: Zolpidem is a sedative-hypnotic used to treat insomnia. It does not have analgesic properties and is not indicated for pain management.

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