Nokea
During ear irrigation, what action should the nurse take if the client becomes nauseated?
- A. Continue the procedure slowly.
- B. Stop the procedure immediately.
- C. Administer an antiemetic medication.
- D. Encourage the client to breathe deeply.
Correct Answer: B
Rationale: During ear irrigation, if the client becomes nauseated, the nurse should stop the procedure immediately to prevent further discomfort or complications. The other options are not appropriate in this context.
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A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?
- A. A soft cotton swab is alright to clean my ears with.
- B. I make sure my ears are dry after I go swimming.
- C. I stop good ear plugs when I practice with the band.
- D. Keeping my diabetes under control helps my ears.
Correct Answer: A
Rationale: Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.
A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is most appropriate?
- A. Assess for signs of dehydration.
- B. Review the client's medication list.
- C. Monitor for signs of hearing loss.
- D. Consult with the healthcare provider.
Correct Answer: D
Rationale: Elevated blood urea nitrogen (BUN) and creatinine levels suggest renal impairment, which can affect drug metabolism and increase the risk of ototoxicity from certain medications. Consulting with the healthcare provider is the most appropriate action to ensure safe care. The other options may be relevant but are not the priority.
A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.)
- A. Chinese stir fry with vegetables.
- B. Broiled chicken breast.
- C. Chocolate espresso cookies.
- D. Chili with tortilla chips.
- E. Green herbal tea with meals.
Correct Answer: B,E
Rationale: The diet recommendations for Ménière's disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies and chili with tortilla chips are high in sodium.
The student nurse is performing a Weber tuning fork test. What technique is most appropriate?
- A. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
- B. Placing the vibrating fork in the middle of the clients head
- C. Placing the vibrating fork in the middle of the clients head
- D. Tapping the vibrating tuning fork against the bridge of the nose
Correct Answer: B
Rationale: The Weber tuning fork test involves placing the vibrating tuning fork in the middle of the client's head and asking in which ear the client hears the vibrations loudest. The other techniques are incorrect.
A client has external otitis. On what comfort measure does the nurse instruct the client?
- A. Applying ice four times a day
- B. Instilling vinegar-and-water drops
- C. Using a home humidifier
- D. Wearing ear plugs during sleep
Correct Answer: C
Rationale: A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not warranted.