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. Provide the child with electronics to watch movies: While distraction can be helpful in managing anxiety or discomfort, it does not directly address the child’s feelings about hair loss. Emotional support specific to the child’s concern is more appropriate in this situation.

B. Tell the child there's no need to cry because this is expected: Minimizing the child’s feelings invalidates their emotional experience and can increase distress. Acknowledging and supporting the child’s emotions is essential for coping during hair loss caused by radiation therapy.

C. Provide the child with a doll that does not have any hair: Giving a doll without hair helps the child normalize hair loss and provides a concrete way to express and cope with feelings. This action demonstrates understanding, empathy, and age-appropriate support for the child’s emotional needs.

D. Tell the child not to worry about their hair loss because their hair will grow back: While it is true that hair often regrows after treatment, reassurance alone does not address the child’s immediate emotional reaction. Supporting the child’s feelings and providing relatable coping strategies is more effective.

A. Administer a bronchodilator following meals. B. Limit the client's food consumption between meals. C. Arrange for a low-protein diet. D. Request non-gas-forming foods from the dietary department.

Correct Answer is D

Explanation

Rationale:

A. Administer a bronchodilator following meals: Bronchodilators should be administered before meals, not after, to help relieve shortness of breath and improve the client’s ability to eat without fatigue or dyspnea. Giving them afterward does not assist with eating difficulties.

B. Limit the client's food consumption between meals: Restricting food intake between meals would reduce overall caloric intake, which is counterproductive for a client who is underweight and experiencing nutritional deficits due to COPD. Frequent small meals are usually recommended.

C. Arrange for a low-protein diet: Clients with COPD who are underweight often need adequate protein to maintain muscle mass and respiratory function. A low-protein diet could worsen malnutrition and impair recovery.

D. Request non-gas-forming foods from the dietary department: Non-gas-forming foods reduce bloating and abdominal discomfort, which can make eating easier for clients with COPD who experience dyspnea. This intervention supports improved caloric intake and minimizes respiratory compromise during meals.

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

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