Nokea
The nurse is preparing to administer eardrops to an infant. The nurse should plan to proceed by taking which step to assure the appropriate instillation of the medication?
- A. Pull down and back on the auricle, and direct the solution onto the eardrum.
- B. Pull up and back on the earlobe, and direct the solution toward the wall of the ear canal.
- C. Pull up and back on the auricle, and direct the solution toward the wall of the ear canal.
- D. Pull down and back on the auricle, and direct the solution toward the wall of the ear canal.
Correct Answer: D
Rationale: The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the nurse pulls down and back on the auricle. The wrist of the dominant hand is rested on the infant's head. The medication is administered by aiming it at the wall of the ear canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back to straighten the auditory canal.
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An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking?
- A. Left leg discomfort
- B. Weak biceps brachii
- C. Triceps muscle spasms
- D. Forearm muscle weakness
Correct Answer: D
Rationale: Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Weak biceps brachii is not a complication of crutch walking. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking.
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions should the nurse include in the plan? Select all that apply.
- A. Avoid heavy lifting.
- B. Sit as much as possible.
- C. Take baths rather than showers.
- D. Limit stair climbing to five times a day.
- E. Gradually increase walking as exercise but stop before becoming fatigued.
- F. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Correct Answer: A,D,E,F
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy and limit stair climbing to five times a day. The client should walk indoors for the first week and then gradually increase walking as exercise, but stop before becoming fatigued. The client should avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also told to avoid the sitting position for extended periods, to take showers rather than tub baths, avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon has given permission to do so.
The nurse is performing a prenatal examination on a client in the third trimester. The nurse begins an abdominal examination that includes Leopold maneuvers. What information should the nurse be able to determine after performing the assessment's first maneuver?
- A. Fetal descent
- B. Placenta previa
- C. Fetal lie and presentation
- D. Strength of uterine contractions
Correct Answer: C
Rationale: The first maneuver, the fundal grip, determines the contents (size, consistency, shape, and mobility) of the fundus (either the fetal head or breech) and thereby the fetal lie. Fetal descent is determined with the fourth maneuver. Placenta previa is diagnosed by ultrasound and not by palpation. Leopold maneuvers are not performed during a contraction.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.
Which action should the nurse take before performing a venipuncture to initiate continuous intravenous (IV) therapy?
- A. Apply a cool compress to the affected area.
- B. Inspect the IV solution and expiration date.
- C. Secure a padded arm board above the IV site.
- D. Apply a tourniquet below the venipuncture site.
Correct Answer: B
Rationale: IV solutions should be free of particles or precipitates to prevent trauma to veins or a thromboembolic event; in addition, the nurse avoids administering IV solutions whose expiration date has passed to prevent infection. Cool compresses cause vasoconstriction, making the vein less visible, smaller, and more difficult to puncture. Arm boards are applied after the IV is started and are used only if necessary. A tourniquet is applied above the chosen vein site to halt venous return and engorge the vein; this makes the vein easier to puncture.