The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

Refer the caregiver to an audiologist.

Explain to the caregiver this a normal finding.

Discuss the importance of prophylactic antibiotics.

Schedule the toddler for a tympanostomy procedure.

Answer and Explanation

The Correct Answer is B

A. Refer the caregiver to an audiologist: Referral to an audiologist is indicated if there are concerns about hearing loss, not for normal anatomical variations of the eustachian tubes.

B. Explain to the caregiver this is a normal finding: In toddlers, the eustachian tubes are naturally shorter and more horizontal, which predisposes them to ear infections. Educating the caregiver about this normal anatomy helps them understand the cause without unnecessary concern.

C. Discuss the importance of prophylactic antibiotics: Routine prophylactic antibiotics are not recommended for preventing recurrent ear infections due to normal eustachian tube anatomy, as overuse can lead to resistance.

D. Schedule the toddler for a tympanostomy procedure: Tympanostomy tubes are only considered for children with recurrent or persistent otitis media with effusion causing hearing loss or complications, not for normal anatomical predisposition alone.

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Correct Answer is C

Explanation

A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.

B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.

C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.

D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.

A. Assess the level of consciousness and vital signs for both clients. B. Review the plan of care and the medications that are due for both clients. C. Complete a head-to-toe assessment of the client with pneumonia. D. Change the surgical dressing to observe the appearance of the incision.

Correct Answer is A

Explanation

A. Assess the level of consciousness and vital signs for both clients: Assessing vital signs and mental status identifies immediate changes in condition, particularly in critically ill clients. This is a priority because it helps detect life-threatening complications early.

B. Review the plan of care and the medications that are due for both clients: While important for planning interventions, reviewing the plan does not address immediate client safety and physiological status, which takes priority.

C. Complete a head-to-toe assessment of the client with pneumonia: A comprehensive assessment is valuable, but initial priority is rapid evaluation of vital signs and consciousness to identify urgent issues in the mechanically ventilated client.

D. Change the surgical dressing to observe the appearance of the incision: Dressing changes are important for infection prevention, but they are not emergent unless there are signs of acute bleeding or infection. Immediate physiologic assessment takes precedence.

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The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

Correct Answer is C

Explanation

The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?

Correct Answer is A

Explanation

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