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 A
Explanation
A. After a myocardial infarction, it is important to monitor the client’s blood pressure before they start ambulating to assess their hemodynamic stability. Changes in blood pressure during or after ambulation could indicate problems such as orthostatic hypotension or cardiovascular instability.
B. While monitoring urinary output is important for assessing renal function and fluid balance, it is not the most immediate concern when preparing the client to ambulate post-MI. The priority is to ensure cardiovascular stability and safety during ambulation, so other interventions take precedence in this situation.
C. Dietary teaching about a cardiac diet is important for long-term management and recovery after an MI. However, it is not the immediate concern when the client is preparing to ambulate for the first time. The priority at this moment is to ensure the client’s safety and stability during the initial physical activity.
D. Vital signs should certainly be monitored, but the more immediate concern when the client is preparing to ambulate is ensuring cardiovascular stability and assessing any potential risk factors that could arise during the activity.
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