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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Provide the client with a stool softener: Clients with thrombocytopenia are at increased risk for bleeding, including gastrointestinal bleeding. Hard stools can cause straining during defecation, which may lead to rectal bleeding. Administering a stool softener helps prevent constipation and reduces the risk of bleeding from the gastrointestinal tract.
B. Remove fresh flowers from the client's room: This intervention is appropriate for clients who are immunocompromised to prevent infection, but it is not specifically necessary for thrombocytopenia unless the client also has neutropenia. The main concern in thrombocytopenia is bleeding, not infection.
C. Avoid serving the client raw vegetables: While raw vegetables may carry a risk of infection, thrombocytopenia alone does not require dietary restrictions for raw vegetables. Safe food handling is important, but preventing bleeding is the primary focus of care.
D. Encourage the client to floss daily: Flossing can increase the risk of gum bleeding in clients with thrombocytopenia. Oral hygiene should be maintained gently with soft-bristled toothbrushes, but daily flossing is not recommended because it may cause unnecessary bleeding.
Correct Answer is A
Explanation
Rationale:
A. A newborn who has forceful vomiting with feedings: Forceful vomiting in a newborn may indicate pyloric stenosis, gastrointestinal obstruction, or other serious conditions that can quickly lead to dehydration and electrolyte imbalance. This is an urgent finding requiring immediate assessment to prevent rapid deterioration.
B. A newborn who has a heart rate of 160/min while crying: A heart rate of 160/min is within the expected range for a newborn (120–160/min) during activity or crying. While monitoring is necessary, this finding is not immediately concerning and does not require urgent intervention.
C. A newborn who is 24 hr of age and has blood-tinged vaginal discharge: A small amount of blood-tinged vaginal discharge (pseudomenstruation) is a normal hormonal response in female newborns due to maternal estrogen withdrawal. This is an expected finding and does not require urgent assessment.
D. A newborn who is 12 hr of age and has not voided: While monitoring urinary output is important, a newborn may normally not void within the first 12 hours of life. Assessment is needed, but it is not as urgent as forceful vomiting, which can quickly cause serious complications.
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