The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Using the smallest speculum to decrease the amount of discomfort

Once the speculum is in the ear, releasing the traction

Tilting the person's head forward during the examination

Pulling the pinna up and back before inserting the speculum

Answer and Explanation

The Correct Answer is D

A. Smallest speculum: The smallest speculum may not provide the best view of the ear canal and tympanic membrane, especially in adults. The correct size should be chosen for adequate visualization.

B. Releasing the traction: Traction should be maintained to stabilize the ear and allow a better view of the ear canal.

C. Tilting the person's head forward: This is not the ideal positioning for the ear examination. The head should be tilted slightly away to straighten the ear canal.

D. Pulling the pinna up and back: This helps straighten the ear canal, especially in adults, providing better visualization during the otoscopic examination.

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Correct Answer is B

Explanation

A. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.

B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.

C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.

D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.

A. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm. B. Refer the individual for further evaluation. C. Check for the presence of claudication. D. Consider this finding as normal, and proceed with the peripheral vascular evaluation.

Correct Answer is D

Explanation

A. Asking about cramping or tingling is unnecessary without other signs of compromised circulation.

B. Referral is not needed if perfusion is adequate.

C. Checking for claudication relates to arterial insufficiency, not absence of ulnar pulse.

D. Proceeding with the evaluation is appropriate if perfusion is adequate, as indicated by normal capillary refill and warm skin.

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The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Correct Answer is B

Explanation

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

Correct Answer is D

Explanation

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The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

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