A nurse is preparing to perform an irrigation to remove a buildup of cerumen from a client's ear. Which of the following actions should the nurse take?
Aim the stream of water directly at the cerumen impaction.
Use cool water to flush the cerumen from the ear canal.
Instill cerumen-softening drops before the irrigation.
Remind the client to use a cotton swab periodically to remove cerumen.
The Correct Answer is C
A. Aim the stream of water directly at the cerumen impaction:
This may injure the tympanic membrane. Irrigation should be directed at the superior wall of the canal.
B. Use cool water to flush the cerumen from the ear canal:
Cool water can cause dizziness or nausea due to stimulation of the vestibular system. Body-temperature water is preferred.
C. Instill cerumen-softening drops before the irrigation:
Softening the cerumen (e.g., with mineral oil or hydrogen peroxide solution) makes irrigation more effective and comfortable.
D. Remind the client to use a cotton swab periodically to remove cerumen:
Cotton swabs can push cerumen deeper and risk damage to the ear canal or drum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who is 4 days postpartum and has lochia serosa
This is an expected finding in the healing process.
B. A client who is 3 days postpartum and has not had a bowel movement
Common postpartum; not urgent unless severe discomfort or obstruction is present.
C. A client who is 1 day postpartum and has not voided in 8 hr
Urinary retention increases the risk of uterine atony and postpartum hemorrhage-must be addressed urgently.
D. A client whose fundus is 2–4 cm below the umbilicus on day 2
Normal involution of the uterus; not concerning.
Correct Answer is A
Explanation
A. Has a vocabulary of four words:
By 24 months, toddlers should say at least 50 words and begin combining two words. A vocabulary of only four words is delayed speech development.
B. Jumps with both feet:
This is a normal gross motor milestone for a 2-year-old.
C. Weighs 12 kg (26.5 lb):
This is within the normal weight range for a 24-month-old.
D. Can draw a circle:
Some 2-year-olds may begin to imitate circular strokes, so this is not a concern.
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