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.
The Correct Answer is C,A,B,D
Rationale
1. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.
2. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.
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. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assisting a client with urinary urgency and incontinence with a bedpan is a basic care task that the UAP can perform under supervision.
B. A client with continuous urinary bladder irrigation via a 3-way catheter requires tasks that involve monitoring and potentially troubleshooting the system, which are within the PN's scope of practice and not appropriate for a UAP.
C. Changing a urinary condom catheter is a routine task that can be performed by a UAP, as it does not require complex decision-making or assessment skills.
D. Managing a full urinary bedside drainage unit after receiving a diuretic is a task that the UAP can handle as long as there are no specific complications or concerns to address.
Correct Answer is B
Explanation
A. Encouraging the client to proceed with the surgery may dismiss their valid fears and does not address the underlying emotional concerns. It is important to acknowledge the client’s feelings rather than pressuring them to continue.
B. Notifying the charge nurse of the client’s concerns ensures that the client’s emotional state and any potential issues with informed consent are addressed appropriately. The charge nurse can facilitate further discussion with the surgical team to ensure the client’s concerns are managed and that the consent remains valid.
C. Documenting the client’s concerns is important for legal and clinical reasons, but it does not address the client’s immediate emotional needs or resolve their fears. The priority is to ensure the client’s concerns are addressed and escalated if necessary.
D. Reminding the client that consent has already been obtained does not validate their current emotional concerns and can be dismissive. The focus should be on addressing the client’s anxiety and exploring their concerns.
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