Nursing Interventions & Clinical Skills 6th Edition by Anne Griffin, Potter, Ostendorf – Test Bank
MULTIPLE CHOICE
1. The nurse prepares to remove the patient’s soft contact lenses. Which intervention should the nurse implement to remove the lenses without traumatizing the cornea?
a. Irrigate the eye with 50 mL of a sterile saline solution.
b. Pull the lid down and instruct the patient to blink.
c. Pinch the sides of the lens together and pop it out.
d. Move the lens to the sclera and compress the lens gently.
ANS: D
To remove a soft contact lens from a patient’s eye, the nurse moves the lens to the sclera and gently compresses it. This maneuver disrupts the surface tension holding the lens to the eye, allowing the nurse to lift the lens off the eye without traumatizing the cornea. The nurse avoids flooding the eye with irrigation solution because it increases the risk of losing the lens. The nurse asks the patient to blink to eject a hard lens. The nurse avoids pinching the lens since that would risk corneal trauma.
DIF: Cognitive Level: Comprehend REF: Page 274, Box 11-1
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
2. The nurse irrigates the patient’s eye after the patient splashes an irritating liquid into it. Which intervention does the nurse implement to prevent injury during eye irrigation?
a. Positions the patient in high-Fowler’s position during the procedure
b. Prevents the tip of the irrigating system from contacting the eyeball
c. Reassures the patient that the eye cannot be closed during irrigation
d. Allows the irrigating solution to run from the outer to the inner canthus
ANS: B
The nurse prevents additional injury to the patient’s eye during the eye irrigation by maintaining the irrigation system tip away from the eye. The nurse positions the patient in the side-lying position on the side of the affected eye to control the flow of irrigation solution. The patient is allowed to blink periodically during the irrigation. The nurse directs the irrigation solution to flow from the inner to the outer canthus to prevent contamination of the eye from a contaminated area.
DIF: Cognitive Level: Remember REF: Page 273
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
3. The nurse and the patient discuss the patient’s need for a hearing aid. What information does the nurse include in patient teaching?
a. An in-the-ear hearing aid is easy to manipulate.
b. The patient’s specific needs and abilities are determining factors.
c. The choice of a hearing aid is basically a financial matter.
d. Behind-the-ear models are inferior to the other types.
ANS: B
The patient’s specific needs and abilities are the determining factors in selecting a model of hearing aid for use. Hearing aids are available in many styles to suit a patient’s individual needs. In-the-ear hearing aids are a poor choice for a patient with impaired manual dexterity because they are small. Behind-the-ear hearing aids are suitable for mild-to-profound hearing loss. Choosing a hearing aid is partially a financial decision, but not all models suit a patient’s needs effectively.
DIF: Cognitive Level: Comprehend REF: Page 280, Table 11-1
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
4. The nursing assistive personnel (NAP) reports that the hearing-impaired patient is usually alert and oriented with the hearing aid in place, but the patient is not responding to verbal communication this morning. What action should the nurse implement first?
a. Document that the patient’s neurological status is poor.
b. Assess the patient for clinical indicators of a stroke.
c. Remove the hearing aid and clean it with a stiff brush.
d. Instruct NAP to check the hearing aid battery.
ANS: D
Because the patient is usually alert and oriented, the nurse realizes that the most likely cause of the patient’s change in hearing is a defective hearing aid battery. The nurse directs the NAP to check the battery first because this is also a simple factor to eliminate. After checking the batteries, the nurse instructs the NAP to clean the hearing aid with the brush supplied by the manufacturer, which is the brush that the patient uses regularly. The nurse does not know yet whether the patient’s neurological status is poor. The NAP reports clinical indicators of normal neurological function, making a stroke unlikely.
DIF: Cognitive Level: Analyze REF: Page 282
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
5. The nurse instructs the patient on how to care for the hearing aid at home. What information should the nurse include in patient teaching to prevent damage to the hearing aid?
a. Store the hearing aid with a desiccant.
b. Wash the hearing aid in hot soapy water.
c. Keep the hearing aid in the bathroom.
d. Clean the hearing aid with a pipe cleaner.
ANS: A
The nurse instructs the patient to store the hearing aid in a dry container with a desiccant to keep moisture and heat away from the device because moisture and heat can destroy the delicate electronic components of the hearing aid. The nurse instructs the patient to avoid immersing the hearing aid and inserting objects into it. The nurse also instructs the patient to avoid storing the hearing aid in the kitchen or bathroom to prevent exposure to moisture and heat.
DIF: Cognitive Level: Comprehend REF: Page 282
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
6. The nurse is preparing to remove cerumen from an older adult’s ear. Nursing care is appropriate if the nurse uses which procedure?
a. Applies slight negative pressure to the ear canal
b. Asks the patient not to move while the ear is being irrigated
c. Cleans the ear canal with a soft cotton swab to remove any remaining cerumen
d. Instills cool irrigating fluid to break down the cerumen in the ear canal
ANS: B
The nurse prepares the patient by explaining the procedure, including the need to remain still while the ear is being irrigated. To prevent damage to the tympanic membrane, negative pressure is never applied to the ear canal. The nurse avoids inserting a cotton swab into the ear canal because it is likely to push cerumen further into the ear. Cool irrigating fluid is contraindicated because it can cause nausea and vertigo.
DIF: Cognitive Level: Apply REF: Page 277
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
7. The patient asks the nurse to irrigate both ear canals to improve hearing and comfort. The patient has bilateral brown ear drainage and a history of a right mastoidectomy and perforation of the left tympanic membrane. Which intervention should the nurse implement first?
a. Inform the patient that the ears are infected.
b. Perform an otoscopic examination of the canals.
c. Collaborate with the audiologist about a hearing aid.
d. Irrigate the ear canals with warm saline solution.
ANS: B
The nurse completes the ear assessment with an otoscopic examination of the ear canals to provide comprehensive patient data to the healthcare provider. The nurse wants to observe cerumen, the tympanic membrane, and origin of the drainage in both ears. He or she avoids irrigating an ear with drainage because the drainage implies that the tympanic membrane is impaired. The nurse avoids sharing a diagnostic conclusion with the patient because he or she does not know that the ears are infected. The nurse’s scope of practice does not provide for collaboration with the audiologist about the need for a hearing aid. This is done by the healthcare provider after a thorough assessment to determine the patient’s plan of care and therapeutic regimen.
DIF: Cognitive Level: Analyze REF: Page 276
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
8. The nurse assesses a 3-year-old patient with a dried bean in the left ear canal. Which action should the nurse implement?
a. Wait for the bean to fall out.
b. Examine the ears with an otoscope.
c. Collaborate with the healthcare provider.
d. Irrigate the ear to flush out the bean.
ANS: C
The nurse inspects the ears visually without the aid of an otoscope to complete the nursing assessment and then collaborates with the healthcare provider to remove the bean. The bean is not likely to fall out because it is more likely to increase in size by being in the moist environment of the ear canal. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and make it harder to remove. The nurse avoids irrigating the patient’s ear canal because the positive pressure from the irrigation solution is likely to affect the bean and make it harder to remove. In addition, a dried bean will absorb water, and its size will increase, further aggravating its removal.
DIF: Cognitive Level: Analyze REF: Page 276
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
9. The nurse irrigates the patient’s right ear with saline solution to improve hearing. Which unexpected outcome of ear canal irrigation does the nurse prevent by preparing the irrigation solution properly?
a. Patient hearing acuity remains stable.
b. Patient senses that irrigant is slightly warm.
c. Patient complains of nausea and vertigo.
d. Patient drainage contains brown particles.
ANS: C
The nurse expects to irrigate the patient’s ear canal without causing patient discomfort, pain, nausea, or vertigo by warming the irrigation solution before instilling it. The nurse expects the patient to sense the warmth of the irrigation solution; this is an expected outcome. Irrigation drainage from the ear containing brown particles is consistent with clinical indicators for effective ear irrigation because this is evidence of cerumen removal; this is an expected finding if cerumen was in the ear canal before the procedure. Failure of patient hearing to improve after irrigation is a possible unexpected outcome, but it is not influenced by warming of solution.
DIF: Cognitive Level: Apply REF: Page 277
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
10. The nurse is instructing a patient on the procedure to remove a rigid contact lens. Instruction by the nurse is correct if the patient uses which technique?
a. Slides lens onto the sclera and pinches off the lens
b. Draws periorbital skin taut and asks the patient to blink
c. Uses a bulb syringe and applies suction to the lens
d. Squeezes the upper and lower lids together to pinch the lens
ANS: B
To remove a hard lens from a patient’s eye, the nurse draws the skin surrounding the eye tightly and instructs the patient to blink. Pulling the skin creates mild tension, which the eyelid uses to dislodge the lens from the cornea. Sliding a contact lens onto the sclera and pinching off the lens is the procedure to remove a soft contact lens. To prevent a corneal abrasion, the nurse avoids using suction to remove a contact lens. He or she avoids squeezing the eyelids together to prevent eye and conjunctival trauma from the hard lens.
DIF: Cognitive Level: Apply REF: Page 274, Box 11-1
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
Reviews
There are no reviews yet.