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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.
B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.
C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.
D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.
Correct Answer is D
Explanation
A. Warming the stethoscope: Improves comfort but is not the first step.
B. Bending the knees: Helps relax abdominal muscles but is done after bladder emptying.
C. Exposing only the abdomen: Ensures privacy but does not affect comfort as much as an empty bladder.
D. Emptying the bladder relieves pressure and discomfort, allowing for a thorough and accurate examination.
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