The practical nurse (PN) is administering otic drops to an adult who has a ruptured eardrum. Which action should the PN implement?
Collect ear drainage for culture.
Warm the drops to room temperature.
Don sterile gloves to instill the drops.
Insert the dropper into the ear canal.
The Correct Answer is B
A. Collect ear drainage for culture:
May be indicated if ordered, but not routine before instillation of drops.
B. Warm the drops to room temperature:
Prevents dizziness or nausea from instilling cold drops and promotes comfort.
C. Don sterile gloves to instill the drops:
Clean technique is used for otic medications, not sterile gloves.
D. Insert the dropper into the ear canal:
Risk of trauma and contamination; dropper should remain above canal opening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Instruct the UAP in repositioning the urinary drainage bag: The bag should be kept below the bladder level to prevent backflow and infection risk; positioning above the bladder is unsafe.
B. Document the amount and appearance of the client's urine: Important but not the first action when there’s an immediate risk of infection from improper drainage bag positioning.
C. Offer to cover the client's arms and chest with the blanket: Comfort is secondary to infection prevention and safety.
D. Confirm with the client of being ready to go to the day room: Communication is important but safety comes first.
Correct Answer is ["B","C","D"]
Explanation
A. Pulse rate 102:This is actually a normal heart rate for an infant (the typical range is 100 to 160 beats per minute). Pain usually causes tachycardia. If the infant were in significant pain, you would expect a heart rate much higher than 102.
B. Facial grimaces:In infants, facial grimacing, a furrowed brow, or chin quivering are among the most reliable behavioral indicators of pain.
C. Knees drawn to chest:Drawing the knees up to the chest is a classic behavioral sign of abdominal pain or distress in an infant, especially following abdominal surgery like a pylorotomy.
D. Restlessness:Restlessness, irritability, and the inability to be easily consoled are common signs that an infant's pain is not well-controlled.
E. Temperature 98.6° F (37.0° C):This is a normal body temperature. While a fever can sometimes be associated with the inflammatory response or infection, it is not used as a clinical indicator to assess the immediate effectiveness of an analgesic for acute postoperative pain.
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