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","B","D"]
Explanation
Rationale:
A. Inability to concentrate: Hypoglycemia reduces glucose availability to the brain, leading to cognitive changes such as difficulty concentrating, confusion, or irritability. This neurologic symptom is an early and common indicator of low blood glucose.
B. Tremors: Trembling or shakiness occurs due to autonomic nervous system activation in response to low blood glucose. Catecholamine release stimulates muscle activity, making tremors a classic sign of hypoglycemia.
C. Acetone breath odor: Acetone or “fruity” breath is associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. It indicates fat metabolism due to insulin deficiency, not low blood glucose.
D. Diaphoresis: Profuse sweating is a sympathetic nervous system response to hypoglycemia. It often accompanies other adrenergic symptoms such as palpitations, anxiety, and tremors, signaling low blood sugar.
E. Polydipsia: Excessive thirst is a symptom of hyperglycemia and is not associated with hypoglycemia. It occurs when high blood glucose leads to osmotic diuresis and fluid loss.
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.
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