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 D
Explanation
A. This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B. Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C. Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D. This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.
Correct Answer is A
Explanation
A. Positioning the package of gauze pads on a sterile field is an appropriate action to maintain sterility and ensure that all items used in the procedure remain uncontaminated. However, this step should be considered only if the solution was poured correctly and the sterility of the gauze pads and solution has been maintained.
B. Discarding the open bottle of solution is not necessary unless it has been contaminated. If the solution is still sterile and has not been contaminated (e.g., by touching non-sterile surfaces), there is no need to discard it. The focus should be on ensuring that the solution and all other items remain sterile.
C. Recapping the solution is not recommended because it can lead to contamination. Instead, the solution should be left open or covered with a sterile cap, if provided. Applying sterile gloves is essential for maintaining sterility during the dressing change procedure, but this should be done after ensuring that all supplies and steps are in order.
D. This action would be necessary only if there was a contamination issue or if the sterility of the supplies or solution was compromised. If the sterile technique was not followed properly or there was a risk of contamination, starting the procedure again with new supplies would be appropriate.
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