While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?
"When I use this technique the medication will not run out of the ear."
“This opens the ear canal, allowing medication to reach the inner ear region.”
“This is the safest and easiest way to administer this medication.”
“When I use the technique, your child experiences less pain.”
The Correct Answer is B
A. "When I use this technique the medication will not run out of the ear."
This explanation is not entirely accurate. While pulling the auricle down and back may help prevent ear drops from immediately dripping out of the ear, the primary purpose of this technique is to straighten the ear canal, facilitating the passage of the medication into the inner ear region for optimal effectiveness. The prevention of medication runoff is a secondary benefit.
B. “This opens the ear canal, allowing medication to reach the inner ear region.”
This explanation is correct. Pulling the auricle down and back helps to straighten the ear canal, making it easier for the ear drops to enter the ear canal and reach the inner ear where they can effectively treat the condition. This is the main purpose of using this technique.
C. “This is the safest and easiest way to administer this medication.”
While pulling the auricle down and back is a commonly used technique for administering ear drops, describing it as the safest and easiest way may not fully capture its purpose. Safety and ease of administration are important considerations, but the primary rationale for this technique is to facilitate the delivery of medication to the inner ear.
D. “When I use the technique, your child experiences less pain.”
This explanation is inaccurate. Pulling the auricle down and back may not directly reduce pain. The main purpose of this technique is to ensure that the medication reaches the inner ear region for effective treatment. While discomfort during administration may be minimized with proper technique, the primary focus is on medication delivery rather than pain reduction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A room with a toddler who has pneumonia.
This option is not ideal because both RSV and pneumonia are respiratory infections that can spread to other patients. Placing these two patients together could increase the risk of cross-infection.
B. A private room with reverse isolation.
Reverse isolation is typically used to protect immunocompromised patients from acquiring infections from others. However, in the case of RSV, reverse isolation is not necessary because RSV primarily affects infants and young children who are generally not immunocompromised. Therefore, this option is not appropriate for an infant with RSV.
C. A private room with contact/droplet precautions.
This option is the most appropriate. RSV is primarily spread through respiratory droplets and direct contact with respiratory secretions. Placing the infant in a private room with contact/droplet precautions helps to minimize the risk of transmission to other patients. Healthcare workers and visitors entering the room should adhere to appropriate precautions, including wearing personal protective equipment (PPE) such as masks, gloves, and gowns.
D. A room with an infant who has croup.
Placing an infant with RSV in the same room as an infant with croup is not ideal because both conditions involve respiratory symptoms and may increase the risk of cross-infection.
Correct Answer is B
Explanation
A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.
B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.
C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.
D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.
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