The nurse assesses a client who is 3 years old and the mother reports the child has a dried bean in the left ear canal. Which should the nurse implement?
1. Wait for the bean to fall out.
2. Examine ears with otoscope.
3. Collaborate with the provider.
4. Irrigate ear to flush out the bean.
3
3. The nurse inspects the ears visually without the aid of an otoscope to complete the nursing assessment and then collaborates with the provider to remove the bean.
1. The nurse avoids providing false information to the parent because the bean is not likely to fall out; the bean is more likely to increase in size by enclosure the moist environment of the ear canal.
2. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and increase the difficulty of removing the bean.
4. The nurse avoids irrigating the client's ear canal because the positive pressure from the irrigation solution is likely to affect the bean and increase the difficulty of removing it. In addition, a dried bean will absorb water, increase the size of the bean, and further aggravate bean removal.
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A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 ° F (35.6 ° C). What action by the nurse takes priority?
a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.
The nurse differentiates a type of topical medication that is an oil-based emulsion to be used on dry skin as a(n) _________________
ANS:
The nurse would reinforce to a client who is about to undergo liposuction for removal of excess fatty tissue that
a. bed rest is required for 24 hours after suction lipectomy. b. final results may take up to 6 months to appear. c. only small amounts of tissue can be removed at one time. d. the client cannot receive analgesics after liposuction for several days.
The nurse wants to use massage to promote relaxation. In which patient diagnosis would massage be potentially contraindicated?
a. Spinal cord injury b. Hypertension c. Acute asthma d. Crohn's disease