A nurse is caring for a patient who has a right-sided acoustic neuroma, resulting in impairment of cranial nerves IX and
X. Which of the following interventions should the nurse implement?
Avoid using warm water to wash the patient’s face.
Apply an eye patch to the patient’s right eye.
Provide range-of-motion exercises to the patient’s neck and shoulders.
Place suction equipment at the patient’s bedside.
The Correct Answer is D
Choice A rationale
Avoiding warm water to wash the patient’s face is not typically necessary for a patient with a right-sided acoustic neuroma.
Choice B rationale
Applying an eye patch to the patient’s right eye is not typically necessary unless the patient is experiencing double vision, which is not a common symptom of acoustic neuroma.
Choice C rationale
Providing range-of-motion exercises to the patient’s neck and shoulders is not typically necessary for a patient with a right-sided acoustic neuroma.
Choice D rationale
Placing suction equipment at the patient’s bedside can be helpful if the patient is experiencing difficulty swallowing or has a risk of aspiration due to impairment of cranial nerves IX and X111213.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1160"]
Explanation
Step 1: Convert All Fluid Intake to Milliliters (mL)
To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:
- 1 cup of coffee = 240 mL
- 4 oz of orange juice = 118.3 mL
- 3 oz of water = 88.7 mL
- 1 cup of flavored gelatin = 236.6 mL
- 1 cup of tea = 240 mL
- 5 oz of broth = 147.9 mL
- 3 oz of water (another serving) = 88.7 mL
Step 2: Calculate Total Fluid Intake
Add all the converted fluid amounts together:
- Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL
Step 3: Round to the Nearest Whole Number
Round the total to the nearest whole number:
- Rounded total = 1,160 mL
The nurse should record 1,160 mL on the patient’s chart.
Correct Answer is C
Explanation
Choice A rationale
Bumetanide is a diuretic, which means it helps your body get rid of extra water. This can make you urinate more often. Taking the second dose at night could disrupt your sleep.
Choice B rationale
While it’s important to monitor fluid intake when taking a diuretic, there’s no specific requirement to limit fluid intake to 1.5 liters a day. Fluid needs can vary based on individual circumstances.
Choice C rationale
Bumetanide can sometimes cause hearing changes or loss, which is usually reversible once the medication is stopped. Therefore, patients should report any changes in hearing to their healthcare provider.
Choice D rationale
Bumetanide can cause the body to lose potassium, which is an important nutrient for heart function. Therefore, it’s usually recommended to consume foods high in potassium, not avoid them.
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