Nokea
The nurse is observing a staff member perform ear irrigation for an adult client with impacted cerumen. The nurse should intervene if the staff member is observed
- A. using a slow, steady flow of solution to irrigate the ear canal
- B. placing the client in a lying position with the head tilted toward the affected ear
- C. straightening the ear canal by pulling the pinna down and back
- D. directing the tip of the syringe and irrigation solution toward the top of the ear canal
Correct Answer: C
Rationale: Pulling the pinna down and back is incorrect for adults; it should be up and back. Slow flow , head tilt , and directing solution upward are correct.
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An 18-month-old child has been placed in Bryant's traction. The nurse knows that the traction is properly applied when:
- A. the affected leg is extended and attached to traction at the foot of the bed.
- B. the legs are at right angles to the child's body and the buttocks are two inches off the bed.
- C. the legs are at right angles to the child's body and the nurse can just put his/her fingers underneath the child's buttocks.
- D. the affected leg is extended and attached to traction at the foot of the bed and there is a vertical pull at the popliteal area.
Correct Answer: C
Rationale: Bryant's traction for infants involves both legs at 90 degrees to the body, with buttocks slightly off the bed (fingers can fit underneath), ensuring proper alignment and traction force.
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?
- A. Act as a witness for the informed consent process
- B. Reinforce information about what the client can expect
- C. Report the surgeon to the ethics board for using an inappropriate consent process
- D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter
Correct Answer: D
Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.
An adult postoperative client vomits, and his abdominal wound eviscerates. What is the best initial action for the nurse to take?
- A. Cover the exposed coils of intestine with sterile moist towels or dressings
- B. Pack the intestines back into the abdominal cavity
- C. Irrigate the exposed coils of intestines with sterile water
- D. Take the client's vital signs
Correct Answer: A
Rationale: Covering exposed intestines with sterile moist dressings prevents infection and drying of tissue, stabilizing the client until surgical intervention. Packing intestines risks contamination, irrigation is inappropriate, and vital signs are secondary to immediate protection.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.