Author Question: The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the ... (Read 69 times)

genevieve1028 · **on:** Jul 22, 2018

The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next?

a. Teach the patient how to use cotton-tipped applicators.
b. Tell the patient to use a bobby pin to extract earwax.
c. Apply gentle, downward retraction of the ear canal.
d. Instill hot water into the ear canal to melt the wax.

Question 2

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use?

a. Avoid commercial mouthwashes.
b. Avoid normal saline rinses.
c. Brush with a hard toothbrush.
d. Brush with an alcohol-based toothpaste.

Question 3

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

a. Insert an oral airway.
b. Place the patient in a flat, supine position.
c. Use undiluted hydrogen peroxide as a cleaner.
d. Quickly proceed while not talking to the patient.

frre432 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: C
When cerumen is visible, gentle, downward retraction at the entrance to the ear canal causes the wax to loosen and slip out. Instruct the patient never to use sharp objects such as bobby pins or paper clips to remove earwax. Use of such objects can traumatize the ear canal and ruptures the tympanic membrane. Avoid the use of cotton-tipped applicators as well because they cause earwax to become impacted within the canal. Instilling cold or hot water causes nausea or vomiting.

Answer to Question 2

ANS: A
Stomatitis causes burning, pain, and change in food and fluid tolerance. Advise patients to avoid alcohol and commercial mouthwash and stop smoking. When caring for patients with stomatitis, brush with a soft toothbrush and floss gently to prevent bleeding of the gums. In some cases, flossing needs to be temporarily omitted from oral care. Normal saline rinses (approximately 30 mL) on awaking in the morning, after each meal, and at bedtime help clean the oral cavity.

Answer to Question 3

ANS: A
If the patient is uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, and then turn the airway sideways and over the tongue to keep the teeth apart. Do not use force. Position the patient on his or her side or turn the head to allow for drainage. Placing the patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa. Even though the patient is debilitated, explain the steps of mouth care and the sensations that he or she will feel. Also tell the patient when the procedure is completed.