Nokea
The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse
- A. instills the ear drops at room temperature
- B. instills the ear drops by placing the dropper into the ear canal
- C. pulls the pinna of the client's ear up and back before instillation
- D. places a cotton ball loosely in the outermost auditory canal after instillation
Correct Answer: B
Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.
You may also like to solve these questions
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
- A. Provide negative room ventilation
- B. Wear a face mask with shield
- C. Wear a particulate respirator mask
- D. Institute airborne precautions
Correct Answer: C
Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
- A. Ask him to blow his nose.
- B. Do a glucose test on his mouth secretions.
- C. Have him rinse his mouth with water.
- D. Ask him if he needs an antiemetic.
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.
A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:
- A. Severe headache
- B. Slight nausea
- C. Decreased urination
- D. Itching
Correct Answer: A
Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.
The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?
- A. Assists the client to use the bedside commode
- B. Dims the lights in the client's room
- C. Places the bed in the lowest position with all side rails raised
- D. Turns off the television in the client's room
Correct Answer: C
Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.
A client with myxedema should be prescribed which diet?
- A. A diet low in fats
- B. A diet high in carbohydrates
- C. A diet high in sugars
- D. A diet low in salt
Correct Answer: B
Rationale: Myxedema (hypothyroidism) slows metabolism, so a high-carbohydrate diet provides energy to support metabolic needs.