The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)
Ask the client to tilt the head slightly toward the affected side.
Position an emesis basin close to the neck under the ear.
Pull the pinna of the ear in an upward and backward direction.
Direct the flow of the warm solution toward the ear canal.
The Correct Answer is B, A, C, D
1. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.
2. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.
3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.
4. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.
5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pallor is not directly related to low serum calcium levels. It may indicate anemia or other conditions, but it is not a primary concern for hypocalcemia.
B. Bruising is generally associated with clotting issues or trauma, not specifically with low serum calcium. Low calcium can affect clotting, but bruising is not a direct or primary symptom of hypocalcemia.
C. Tetany, which includes symptoms like muscle spasms, twitching, and numbness, is a key indicator of low serum calcium levels. Monitoring for tetany is essential in managing clients with malabsorption syndrome who have hypocalcemia.
D. Jaundice is a sign of liver dysfunction or hemolysis, not directly related to low calcium levels. Low serum calcium is not typically associated with jaundice.
Correct Answer is []
Explanation
The child’s symptoms—drowsiness, thick yellow secretions, low respiratory rate, and fever—along with the chest x-ray showing consolidation consistent with pneumonia, indicate that he is experiencing respiratory insufficiency. Respiratory insufficiency occurs when the respiratory system fails to meet the body's oxygen needs or remove carbon dioxide effectively.
Actions to Take:
1. Perform oropharyngeal suctioning
Suctioning is necessary to clear the thick yellow secretions that can obstruct the airway and contribute to respiratory insufficiency. It helps maintain a patent airway and improves the child's ability to breathe.
2. Provide humidified supplemental oxygen
Humidified oxygen helps to maintain airway moisture and improve oxygenation, which is critical for managing respiratory insufficiency. It can also help loosen secretions and alleviate symptoms related to pneumonia.
Parameters to Monitor:
1. Oxygen Saturation
Monitoring oxygen saturation is essential to assess the effectiveness of supplemental oxygen and interventions for respiratory insufficiency. Low oxygen saturation indicates that the respiratory system is not meeting the oxygen demands of the body.
2. Temperature
Temperature monitoring is important to assess the effectiveness of fever management and to monitor for potential worsening of the infection. Elevated temperature can exacerbate respiratory insufficiency and indicate ongoing infection.
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