A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?
Pull the client's pinna down and back to apply the solution.
Perform the procedure using sterile gloves.
Administer the irrigation solution at room temperature to the ear
Apply a stream of pressure as long as the client can tolerate.
The Correct Answer is C
Rationale:
A. Pull the client's pinna down and back to apply the solution.: Pulling the pinna down and back is the correct technique for infants and young children due to the angle of the ear canal. For adults, the pinna should be pulled up and back to straighten the ear canal. Using the incorrect direction can prevent proper visualization and reduce effectiveness of the irrigation.
B. Perform the procedure using sterile gloves.: Ear irrigation is a clean procedure, not a sterile one. The external ear canal is not a sterile environment, and using sterile gloves does not reduce infection risk. Clean gloves provide adequate protection while maintaining proper hygiene during cerumen removal.
C. Administer the irrigation solution at room temperature to the ear.: Using a solution at room temperature prevents stimulation of the vestibular system, which can cause dizziness, nausea, and vertigo. A temperature-neutral solution promotes client comfort and reduces physiologic irritation while effectively helping soften and remove cerumen.
D. Apply a stream of pressure as long as the client can tolerate.: Using forceful or prolonged pressure can damage the tympanic membrane or push cerumen deeper into the canal. Irrigation should be done gently, allowing the solution to flow along the canal wall and stopping immediately if the client reports pain or dizziness to avoid injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Use an electric razor when shaving while taking this medication.": Warfarin is an anticoagulant that increases the risk of bleeding. Using an electric razor reduces the risk of cuts and subsequent bleeding, which is an important safety measure for clients on warfarin therapy.
B. "Take a dose of the medication every 5 minutes for a maximum of three doses": This instruction is inappropriate and unrelated to warfarin. Warfarin is taken orally once daily, and frequent dosing in short intervals could lead to serious bleeding complications.
C. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption or activity. The client should be cautioned about foods high in vitamin K, such as leafy greens, because they can interfere with warfarin’s anticoagulant effect.
D. "This medication can cause hearing loss.": Hearing loss is not a known adverse effect of warfarin. The primary concerns are bleeding risks, bruising, and interactions with other medications or foods.
Correct Answer is A
Explanation
Rationale:
A. Required immunizations: Immunizations are a key aspect of primary prevention, as they protect children from preventable diseases before exposure occurs. Including information about required vaccines at the kindergarten level helps caregivers ensure children are protected and supports community health.
B. Nutrition for children who have diabetes: Nutrition management for children with diabetes is considered secondary or tertiary prevention, as it involves managing an existing condition rather than preventing disease onset. It is not the focus for primary prevention at a general health fair.
C. Emergency disaster planning: While disaster planning is important for safety, it is not classified as primary prevention of disease. It addresses preparedness rather than preventing the initial occurrence of a health condition.
D. Screening for a pediculosis breakout: Screening is a secondary prevention activity because it involves early detection of an existing condition (lice infestation). It does not prevent the initial occurrence of disease, so it is not a primary prevention topic.
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