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 A
Explanation
A. Folic acid deficiency is the most significant maternal factor associated with the development of spina bifida occulta. Adequate folic acid intake before and during pregnancy is crucial for preventing neural tube defects.
B. Preeclampsia is a serious pregnancy complication but does not have a direct link to spina bifida occulta compared to the impact of folic acid deficiency.
C. A short interval between pregnancies is associated with other risks but is not a known direct cause of spina bifida occulta.
D. Tobacco use has various adverse effects on pregnancy and fetal development but is not as directly linked to the risk of spina bifida occulta as folic acid deficiency.
Correct Answer is B
Explanation
A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.
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