The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

Ask the client to tilt the head slightly toward the affected side.

Position an emesis basin close to the neck under the ear.

Pull the pinna of the ear in an upward and backward direction.

Direct the flow of the warm solution toward the ear canal.

Answer and Explanation

The Correct Answer is B, A, C, D

1. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.

2. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.

3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.

4. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.

5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently.

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Correct Answer is ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

A. Have you changed any diapers? B. Have you unwrapped and looked at your baby? C. Have you noticed the baby sleeping? D. Has the family seen the baby yet?

Correct Answer is A

Explanation

A. Diaper changes help assess the baby’s urinary output and general hydration status. If the newborn is producing urine, it suggests proper kidney function and adequate fluid intake, which are essential considerations before transferring the baby to the nursery.
B. While this promotes bonding and allows the mother to assess her baby visually, it does not directly address health indicators such as feeding or elimination, which are critical for ensuring the newborn’s well-being.
C. Noting if the baby is sleeping is a routine observation but does not address the importance of maternal bonding.
D. Whether the family has seen the baby is less critical than ensuring the mother has had early bonding opportunities.

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The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

When the practical nurse (PN) prepares to transfer a 12-hour-old newborn from the birthing suite to the nursery, which question is most important for the PN to ask the mother?

Correct Answer is A

Explanation

Which foot care instruction is most important for the practical nurse (PN) to reinforce that minimizes a long-term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

A client receives a prescription for digoxin 0.25 mg by mouth. The medication is available in 0.125 mg tablets. How many tablets should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

What foods should the practical nurse (PN) recommend to a client as good sources of vitamin K? Select all that apply.

According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.