The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)
Keep the battery door closed during storage.
Observing and reporting any ear drainage after removing the device is crucial. Any drainage could indicate an infection or other issues that require further evaluation by nursing staff.
Store the device on window sill to prevent loss.
Verify that the device is labeled with client's identification.
Remove ear wax from the device's surface.
Correct Answer : B,D,E
A. Keeping the battery door closed during storage is generally a good practice to prevent battery drain; however, it may be more appropriate to keep it open for extended storage to avoid moisture buildup. The PN should clarify proper storage practices.
B. Observing and reporting any ear drainage after removing the device is crucial. Any drainage could indicate an infection or other issues that require further evaluation by nursing staff.
C. Storing the device on a windowsill is not advisable, as this increases the risk of loss or damage. A secure, designated storage area is better for such items.
D. Verifying that the device is labeled with the client's identification is important to prevent mix-ups and ensure proper usage. Proper labeling aids in maintaining accountability and safety in a long-term care setting.
E. Removing ear wax from the device's surface is appropriate as it ensures the hearing aid functions properly and maintains hygiene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- an audible voice when client is trying to communicate, indicates that the client has some air passing through the vocal cords, which may be due to a partially deflated cuff or a speaking valve. This is not a life-threatening situation, but the nurse should ensure that the cuff pressure is adequate and that the client is not experiencing any discomfort or aspiration risk.
B) Incorrect- This may indicate atelectasis, pneumonia, or pleural effusion in that lung area. The nurse should auscultate the client's lungs more thoroughly, monitor the client's oxygenation and ventilation parameters, and report the findings to the provider.
C) Correct- This finding suggests that the client may have a ventilator disconnect, a leak in the circuit, or a cuff leak, which can compromise the client's oxygenation and ventilation. The nurse should immediately check the ventilator connections and tubing, and assess the client's vital signs and oxygen saturation.
D) Incorrect- high-pressure alarm sounds when the client is coughing, which is a common occurrence in mechanically ventilated clients who have increased airway resistance due to secretions, bronchospasm, or coughing. The nurse should suction the client as needed, administer bronchodilators if prescribed, and ensure that the ventilator settings are appropriate for the client's condition.
Correct Answer is A
Explanation
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
- The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
- The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
- The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
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