A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take?
Pull the auricle upward and outward to straighten the ear canal.
Pull the auricle down and back to straighten the ear canal.
Sit the child up to insert the cotton ball into the innermost ear canal.
Sit the child up for 2 to 3 minutes after instilling drops in the ear canal.
The Correct Answer is B
A: Pulling the auricle upward and outward is the correct technique for adults and children over 3 years old, not for a 2-year-old child.
B: Pulling the auricle down and back is the correct technique for straightening the ear canal in children under 3 years old. This allows for proper administration of the eardrops.
C: Sitting the child up to insert a cotton ball into the innermost ear canal is not appropriate. Cotton balls should not be inserted deeply into the ear canal.
D: Sitting the child up for 2 to 3 minutes after instilling drops is not necessary. The child should remain in a position that allows the drops to stay in the ear canal for the prescribed time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: The nurse should check the medication order again to ensure that the correct medication is being administered. This response addresses the client’s concern and ensures patient safety.
B: Telling the client that this is the medication their doctor wants them to take does not address the client’s concern about the color difference and may not ensure the correct medication is given.
C: While it is true that the same medication can come in different colors, this response does not verify the accuracy of the medication being administered.
D: Explaining the purpose of the medication is important, but it does not address the immediate concern about the color difference and the need to verify the medication.
Correct Answer is C
Explanation
A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.
B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.
C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.
D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.
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