Nokea
The best method to remove cerumen from a client's ear involves:
- A. Inserting a cotton-tipped applicator into the external canal.
- B. Irrigating the ear gently.
- C. Using aural suction.
- D. Using a cerumen curette.
Correct Answer: B
Rationale: Gentle irrigation with warm water or saline is the safest and most effective method to remove cerumen, avoiding trauma to the ear canal or eardrum.
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After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
- A. Elevate the sequential compression device (SCD) on two pillows.
- B. Change the settings on the SCD to make the client more comfortable.
- C. Use the SCD to remove dressings and bathe the leg.
- D. Discontinue the SCD when the client is ambulatory.
Correct Answer: D
Rationale: The SCD is discontinued when the client is ambulatory, as mobility reduces the risk of thrombosis.
A client has an ileal conduit. Which of the following solutions will be useful to help control odor in the urine collecting bag after it has been cleaned?
- A. Salt water.
- B. Vinegar.
- C. Ammonia.
- D. Bleach.
Correct Answer: B
Rationale: Vinegar neutralizes odors in the urine collecting bag, is safe for use, and helps maintain appliance integrity.
The nurse is caring for a client with a peripherally inserted central catheter (PICC) in the left upper extremity. It would indicate correct nursing care if the nurse
- A. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 5 mL syringe.
- B. slowly flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.
- C. pulsatile flushes each lumen with sterile water in a 10 mL syringe.
- D. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.
Correct Answer: D
Rationale: PICC lines require pulsatile flushing with 0.9% saline in a 10 mL syringe to maintain patency and prevent occlusion.
The nurse is planning a community health class for older adults. Which topic should the nurse prioritize?
- A. discussing and preventing polypharmacy
- B. strategies to stay physically active
- C. staying socially engaged in the community
- D. recommended immunizations
Correct Answer: A
Rationale: Polypharmacy is a critical issue in older adults, increasing the risk of adverse drug events.
The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply.
- A. Urinary incontinence
- B. Pupil dilation
- C. Diarrhea
- D. Altered level of consciousness (LOC)
- E. Constipation
Correct Answer: D,E
Rationale: Hydromorphone, an opioid, can cause altered level of consciousness and constipation. Urinary incontinence, pupil dilation, and diarrhea are not typical side effects.