A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Limit fluid intake.

Monitor client’s cardinal fields of vision.

Encourage ambulation.

Ensure the room is brightly lit.

Answer and Explanation

The Correct Answer is B

Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.

Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.

Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.

Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.

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Correct Answer is B

Explanation

Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.

Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.

Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.

Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.

A. Apply lotion to the skin around the edges of the splint. B. Turn the client every 4 hr. C. Pad the top of the splint with protective dressings. D. The nurse should apply a footplate to the bed.

Correct Answer is C

Explanation

Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.

Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.

Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.

Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.

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A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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