ATI RN
foundation of nursing questions Questions
Question 1 of 5
The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
Correct Answer: A
Rationale: Correct Answer: A. Maintain the irrigation fluid at a warm temperature. Rationale: 1. Warm fluid helps prevent vertigo and nausea by minimizing stimulation of the vestibular system. 2. Cold fluid can cause dizziness and nausea due to the temperature effect on the inner ear. 3. Warm fluid promotes patient comfort and relaxation during the procedure. 4. Cold fluid can lead to vasoconstriction, potentially exacerbating ear discomfort. Summary of other choices: B. Instilling short, sharp bursts of fluid can be uncomfortable and increase the risk of vertigo and nausea. C. Following with a curette may not be necessary if the irrigation effectively removes the impacted cerumen. D. Having the patient stand can increase the risk of falling or losing balance due to potential dizziness from the procedure.
Question 2 of 5
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
Correct Answer: A
Rationale: The correct answer is A: Rinsing the ears with normal saline after swimming. This is because rinsing with normal saline helps to remove excess moisture and debris, preventing bacterial growth that can lead to otitis externa. Avoiding loud noises (B) is important for overall ear health but does not specifically prevent otitis externa. Instilling antibiotic ointments regularly (C) is not recommended as it can disrupt the ear's natural flora. Avoiding cotton swabs (D) is important to prevent injury but does not directly prevent otitis externa.
Question 3 of 5
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action?
Correct Answer: B
Rationale: The correct answer is B: Assisting the patient into a sitting position. The Epley maneuver is used to treat benign paroxysmal positional vertigo by repositioning displaced calcium carbonate crystals in the inner ear. This maneuver involves a series of specific head movements. Starting with the patient in a sitting position allows for proper orientation and positioning for subsequent movements to be effective. Placing the patient in a prone position (A) would not facilitate the correct positioning for the maneuver. Instilling warm saline into the ear (C) is not part of the Epley maneuver. Assessing baseline hearing (D) is unrelated to performing the Epley maneuver.
Question 4 of 5
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
Correct Answer: D
Rationale: The correct answer is D: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale: 1. Blowing the nose can increase pressure in the surgical area and lead to complications. 2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site. 3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications. In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.
Question 5 of 5
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury?
Correct Answer: C
Rationale: Step 1: Trigeminal neuralgia involves severe facial pain, often triggered by touch or movement. Step 2: Rubbing the eye on the affected side can trigger pain due to the trigeminal nerve involvement. Step 3: Therefore, advising the patient to avoid rubbing the eye on the affected side is crucial to prevent pain exacerbation and potential injury. Step 4: Choices A, B, and D are incorrect as they do not directly address the risk of injury related to trigeminal neuralgia.