The nurse is caring for an older client who has difficulty hearing because of suspected wax accumulation. What measures will the nurse take to help this client?
Standard Text: Select all that apply.
1. Instill a cerumenolytic as prescribed prior to the irrigation.
2. Warm the irrigating solution to normal body temperature.
3. After instilling the irrigating solution, use a cotton-tipped applicator to gently dry the ear canal.
4. Use a large-bore syringe to apply enough pressure to loosen the impacted cerumen.
5. Pull the pinna up and back prior to instilling any medications.
Correct Answer: 1,2,5
Rationale 1: Cerumenolytics used prior to irrigation can loosen and help remove impacted cerumen from the ear.
Rationale 2: Solutions placed in the ear should be warmed prior to instillation to prevent the client from experiencing dizziness.
Rationale 3: The risk of cerumen impaction increases with the use of cotton-tipped applicators.
Rationale 4: Ear irrigations should be done with gentle pressure.
Rationale 5: The pinna of adults should be gently pulled up and back prior to instilling ear medications.
Global Rationale: Cerumenolytics used prior to irrigation can loosen and help remove impacted cerumen from the ear. Solutions placed in the ear should be warmed prior to instillation to prevent the client from experiencing dizziness. The pinna of adults should be gently pulled up and back prior to instilling ear medications. The risk of cerumen impaction increases with the use of cotton-tipped applicators. Ear irrigations should be done with gentle pressure.
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