NCLEX Review about Ear Infection
26. The clinic nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which of the following will the nurse avoid when performing the irrigation?
a) position the client to turn the head so that the ear be irrigated is facing upward
b) warm the irrigating solution to a temperature that is close to body temperature
c) direct a slow steady stream of irrigation solution toward the upper wall of the ear canal
d) position the client with the affected side down after irrigation
27. A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure?
a) pulling the pinna down and back before inserting the speculum
b) pulling the earlobe down and back before inserting the speculum
c) using the smallest speculum available
d) tilting the client's head slightly away and holding the otoscope upside before inserting the speculum
28. A nurse is preparing to perform a Weber test on a client. The nurse obtains which item needed to perform this test?
a) a tongue blade
b) a stethoscope
c) a tuning fork
d) a reflex hammer
29. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse prepares to instruct the client's spouse in which measure that will facilitate communication?
a) speak frequently to the client to provide sensory stimulation
b) speak loudly to the client to facilitate hearing
c) speak in a normal tone and face the client when speaking
d) speak directly into the impaired ear to facilitate hearing
30. A nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse instructs the client to:
a) drink liquids through a straw for the next 2 to 3 weeks
b) shower daily to prevent infection
c) avoid air travel
d) resume all normal activities in 1 week
NCLEX Review about Ear Infection:
ANSWERS AND RATIONALE
26) A
- During the irrigation, the client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.
27) D
- In the otoscopic examination, the nurse tilts the client’s head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. A small speculum is used in pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small speculum is used in the adult client.
28) C
- A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client’s forehead or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. The items identified in options A, B, and D are not needed to perform the Weber test.
29) C
- Measures that facilitate hearing in the client with a hearing impairment problem include speaking in a normal tone; avoiding shouting; talking directly to the client while facing the client; and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided.
30) C
After ear surgery, the client needs to be instructed to avoid air travel, avoid drinking through a straw for 2 to 3 weeks, and to avoid coughing excessively. In addition, the client should avoid straining when having a bowel movement, as well as washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.
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NCLEX Review about Ear Infection (31-35)
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