A nurse is preparing to administer ear drops to a client due to cerumen accumulation. Which of the following actions should the nurse take?

Instruct the client to remain supine for 5 min after administration of the ear drops.

Clean the inner ear canal with a cotton-tipped applicator before administering the ear drops.

Warm the medication to room temperature before administration of the ear drops.

Insert a cotton ball into the client's inner ear canal after administering the ear drops.

Answer and Explanation

The Correct Answer is C

Rationale:

A. The client should remain in a position that allows the medication to stay in the ear canal—typically lying on the opposite side with the affected ear upward during administration, and remaining in that position for about 2–5 minutes after instillation. However, “supine” positioning is not required or optimal, making this statement inaccurate.

B. Cotton-tipped applicators should not be inserted into the inner ear canal because they can push cerumen further in, cause trauma, or damage the tympanic membrane. Only the external ear may be gently cleaned if needed.

C. Ear drops should be warmed to room temperature by holding the bottle in the hands for a few minutes. Cold drops can cause dizziness, vertigo, and discomfort due to stimulation of the vestibular system. Proper temperature improves comfort and safety during administration.

D. A cotton ball may be placed loosely at the outer ear (not inserted into the canal) if recommended, but it should not be pushed into the inner ear canal. Inserting it deeply can block medication absorption and increase risk of impaction or injury.

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Correct Answer is B

Explanation

Rationale:
A. The shoulders are not a reliable location for assessing cyanosis, especially in clients with dark skin. Cyanosis is best observed in areas where skin is thinner and less pigmented, such as mucous membranes and extremities.

B. In clients with dark skin, cyanosis is best assessed in areas with less pigmentation and increased capillary visibility. The palms (as well as nail beds, soles of the feet, and mucous membranes) are more reliable sites because changes in oxygenation are more apparent there.

C. The sacral area is typically assessed for pressure injuries rather than cyanosis. It is not a dependable site for identifying changes in oxygenation status.

D. While traumatized areas may show bruising, swelling, or inflammation, they are not appropriate or reliable sites for assessing cyanosis. Cyanosis assessment should focus on consistent anatomical landmarks like nail beds and mucous membranes rather than injury sites.

A. Continue to monitor the client every 15 min. B. Remove the restraints from the client. C. Encourage the client to attend a group therapy session. D. Offer the client PRN pain medication.

Correct Answer is B

Explanation

Rationale:
A. While clients in restraints must be monitored frequently (typically at least every 15–30 minutes depending on policy), ongoing monitoring is not the priority when the client is calm and no longer exhibiting behavior that necessitates restraints. The nurse should first reassess the need for restraints.

B. Restraints must be discontinued as soon as the client is no longer a danger to themselves or others. Since the client is now calm and cooperative, continued restraint use is no longer justified and may lead to complications such as impaired circulation, skin breakdown, and psychological distress. The nurse should remove restraints promptly while ensuring safety.

C. While therapeutic activities may be appropriate after stabilization, the immediate priority is discontinuation of restraints. Participation in group therapy is not the priority action in this situation.

D. There is no indication of pain in the question stem, and medication is not the priority intervention. The nurse must first discontinue restraints once the client’s behavior is under control and safety is restored.

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A nurse is preparing to administer ear drops to a client due to cerumen accumulation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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