A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?
Firmly push a cotton ball into the ear canal after instilling drops.
Pull the child's ear auricle upward and outward just before instilling drops.
Apply clean gloves and clean the outer ear prior to instilling drops.
Warm the medication container for 10 seconds in a microwave oven prior to installation.
The Correct Answer is C
A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.
B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.
C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.
A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.
B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.
C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.
A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.
B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.
C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Heart rate 110/min: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
B. Capillary refill greater than 3 seconds: Capillary refill time should be less than 2 seconds in a healthy child. A refill time greater than 3 seconds may indicate poor perfusion or dehydration, which is abnormal.
C. Weight gain of 0.9 kg (2 lb) in a year: A weight gain of 2 pounds in a year is below the expected range for a 4-year-old. Children in this age group typically gain around 4-5 pounds per year as they grow.
D. Respiratory rate 32/min: The normal respiratory rate for a 4-year-old child is typically between 20 to 30 breaths per minute. A rate of 32/min is slightly elevated and may indicate respiratory distress or other issues.
Correct Answer is C
Explanation
A. Wrist: Wrist restraints are typically used to prevent older children or adults from pulling at medical devices or dressings. For an infant, wrist restraints can be too harsh and restrictive. They do not prevent the child from bending their arms, which could allow them to reach their face and potentially disrupt the surgical site.
B. Mummy: A mummy restraint involves wrapping the infant’s body tightly with a blanket to restrict movement, typically used for short periods during medical procedures to keep the child still. This type of restraint is too restrictive for postoperative care and does not allow any movement of the arms, making it uncomfortable and unsuitable for continuous use over extended periods.
C. Elbow: Elbow restraints, also known as no-no’s, are designed to prevent the infant from bending their arms. This type of restraint keeps the elbows straight, preventing the child from touching their face and disrupting the surgical site of the cleft lip and palate. It is effective in allowing the infant to move their arms while ensuring that they cannot interfere with the healing area. This method is less restrictive and more humane for postoperative care in an infant.
D. Jacket: Jacket restraints are used to secure the torso, usually to prevent a child from moving out of bed or a chair. This type of restraint is more restrictive and not specific to preventing arm movement. For an infant recovering from cleft lip and palate surgery, jacket restraints would not effectively prevent the child from reaching their face, and they can be excessively confining and distressing for an infant.
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