The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?
Reposition the dropper.
Pull the auricle up and out.
Visualize the ear drum.
Administer the ear drops.
The Correct Answer is B
A. The dropper should already be positioned correctly, with the tip pointing toward the ear canal.
B. For adolescents and adults, the auricle (outer ear) should be pulled up and out to straighten the ear canal. This allows the ear drops to flow directly into the ear canal, avoiding the tympanic membrane (eardrum). Correctly positioning the auricle helps to prevent irritation and discomfort during ear drop administration.
C. While visualizing the eardrum is important for certain procedures, it's not necessary when administering ear drops.
D. The ear drops should be administered after the auricle is pulled up and out to ensure proper placement in the ear canal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B. Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C. Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D. Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.
Correct Answer is D
Explanation
A. While it is generally good practice to measure blood pressure in both arms for a comprehensive assessment, this is not the primary concern with hypocalcemia. Hypocalcemia primarily affects neuromuscular and cardiovascular systems, so while blood pressure monitoring is important, it does not directly address the critical symptoms associated with low calcium levels.
B. Assessing skin turgor is a useful practice for evaluating hydration status and skin elasticity but is not specifically related to the management or symptoms of hypocalcemia. In hypocalcemia, skin changes are not the most relevant concern compared to neuromuscular symptoms.
C. Hypocalcemia can increase the risk of bleeding and bruising due to impaired blood clotting mechanisms. Monitoring for bruising can be an important aspect of assessing the effects of low calcium levels on the client’s hemostatic function. Bruising can be a direct indicator of the impact of hypocalcemia on blood coagulation and is relevant to the clinical management of the condition.
D. Hypocalcemia can affect cardiac function, potentially leading to changes in heart rhythm and rate. Monitoring the rhythm of the pulse is crucial, as it can help identify arrhythmias or other cardiac disturbances associated with low calcium levels.
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