A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?

Tilt the client's head with the affected ear facing up.

Insert the tip of the syringe 2.5 cm (1 in) into the ear canal.

Point the tip of the syringe toward the top of the ear canal.

Use cool fluid for irrigation.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Tilt the client's head with the affected ear facing up: Tilting the head with the affected ear facing up is not recommended. The head should be tilted so the affected ear faces downward, allowing the irrigating fluid to drain out easily and reducing the risk of injury or discomfort.

B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal: The syringe tip should not be inserted deeply into the ear canal. Inserting the tip too far can cause trauma to the ear canal or eardrum. The tip should be placed at the opening of the ear canal to allow for safe irrigation.

C. Point the tip of the syringe toward the top of the ear canal: The syringe should be aimed toward the top or posterior wall of the ear canal, not directly at the eardrum. This allows the fluid to flow along the ear canal and helps prevent injury to the eardrum while effectively flushing the ear.

D. Use cool fluid for irrigation: Cool fluid can cause dizziness or discomfort for the client. It is better to use warm, body-temperature fluid during ear irrigation to ensure the client remains comfortable and to avoid any adverse effects.

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Correct Answer is B

Explanation

Rationale:

A. Keep the casted leg flat for the first 24 hr: The casted leg should not be kept flat for the first 24 hours. Elevating the leg above the heart is important to reduce swelling and promote circulation. Keeping it flat could increase swelling and discomfort.

B. Report any drainage from the casted leg: It is important to report any drainage from the cast, as it could indicate infection or complications, such as a wound underneath the cast. Drainage, especially if it is blood-tinged or excessive, requires prompt evaluation.

C. Apply a heating pad to the casted leg: Applying a heating pad is not recommended as it could increase swelling or cause burns. It is important to keep the cast cool and dry and avoid applying heat, which could affect the skin or underlying tissue.

D. Use a cotton-tip applicator to relieve itching inside the cast: Using a cotton-tip applicator can be harmful because it might push debris deeper into the cast, increasing the risk of infection or injury.

A. Obtain the client's vital signs. B. Notify the rapid response team. C. Perform a neurologic check. D. Turn the client on their side.

Correct Answer is D

Explanation

Rationale:

A. Obtain the client's vital signs: While vital signs are important after a seizure, they are not the priority during the event. The first action should focus on protecting the client from injury and ensuring their airway remains open.

B. Notify the rapid response team: Notifying the rapid response team is not the first step. The nurse should prioritize ensuring the client’s safety during the seizure, including turning them on their side to prevent aspiration or injury.

C. Perform a neurologic check: A neurologic check is important after the seizure has ended to assess for changes in mental status or neurological function. However, during the seizure, the immediate priority is to ensure the client’s safety and airway.

D. Turn the client on their side: This priority action during a tonic-clonic seizure helps maintain the airway, prevents aspiration, and allows any secretions to drain from the mouth. Ensuring safety during the seizure is crucial before performing other assessments.

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A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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