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    Ati rn adult medical surgical 2023 proctored exam

    A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?

    Explanation & Rationale

    Rationale: A. Tilt the client's head with the affected ear facing up: Tilting the head with the affected ear facing up is not recommended. The head should be tilted so the affected ear faces downward, allowing the irrigating fluid to drain out easily and reducing the risk of injury or discomfort. B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal: The syringe tip should not be inserted deeply into the ear canal. Inserting the tip too far can cause trauma to the ear canal or eardrum. The tip should be placed at the opening of the ear canal to allow for safe irrigation. C. Point the tip of the syringe toward the top of the ear canal: The syringe should be aimed toward the top or posterior wall of the ear canal, not directly at the eardrum. This allows the fluid to flow along the ear canal and helps prevent injury to the eardrum while effectively flushing the ear. D. Use cool fluid for irrigation: Cool fluid can cause dizziness or discomfort for the client. It is better to use warm, body-temperature fluid during ear irrigation to ensure the client remains comfortable and to avoid any adverse effects.

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