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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. While avoiding friction can help to prevent skin breakdown, it's not the most important intervention for this client. Frequent position changes are more effective in reducing pressure on the skin and preventing ulcers.
B. Nutrition is important for overall health, but it's not the most immediate concern in this case. Preventing pressure ulcers is the priority.
C. While keeping the skin clean and dry is important, it's not the most effective way to prevent pressure ulcers. Frequent position changes are more important for reducing pressure on the skin.
D. The most effective way to prevent pressure ulcers in immobile clients is to change their position frequently. This helps to relieve pressure on bony areas and promote circulation to the skin. By changing the client's position regularly, the nurse can help to reduce the risk of skin breakdown and the development of pressure ulcers.

A. Allow privacy for the family and client to express their feelings to one another. B. Apply an automatic blood pressure cuff and take readings every 15 minutes. C. Teach the client's family how to use an oral suction device to clear the airway. D. Elevate the head of the client's bed and apply oxygen using a face mask.

Correct Answer is A

Explanation

A. Allowing privacy for the family and client is a compassionate and appropriate action, especially as the client's death is imminent. This respects the client's wishes and provides a supportive environment for the family to process their emotions and say their goodbyes.
B. Continuously measuring blood pressure in this scenario is less appropriate because the client is in the final stages of life and their focus should be on comfort rather than monitoring vital signs. Frequent blood pressure measurements may be distressing for the family and do not align with the goals of end- of-life care, which prioritize comfort and dignity.
C. Teaching the family to use an oral suction device is not appropriate at this stage because the client is actively dying, and such interventions are not typically useful or necessary in end-of-life care. The focus should be on providing comfort rather than invasive procedures or teaching new skills to family members.
D. Applying oxygen and elevating the head of the bed can be appropriate interventions for clients experiencing respiratory distress; however, this may conflict with the advance directive if the directive explicitly states no resuscitative measures

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The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?

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Naxlex Comprehensive Predictor Exams

While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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