Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.

Diminished hearing

Pupils

Lung assessment

Facial nerve assessment

Vertigo

Pain rating

Answer and Explanation

Correct Answer : D,E,F

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

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Correct Answer is B

Explanation

A. Confusion can occur with electrolyte imbalances, including hyperkalemia, but it is not the most common or specific symptom associated with elevated potassium levels. More typical symptoms are related to muscle and gastrointestinal function.
B. Abdominal cramps are a common finding in clients with hyperkalemia (potassium level of 5.8 mEq/L). Elevated potassium can lead to increased gastrointestinal motility and irritability, resulting in symptoms such as abdominal cramps and diarrhea.
C. Positive Chvostek's sign indicates hypocalcemia (low calcium levels) and is not associated with hyperkalemia. This sign reflects increased neuromuscular excitability due to low calcium levels, so it would not be expected in this scenario.
D. Decreased bowel motility is typically associated with hypokalemia (low potassium levels) rather than hyperkalemia. Elevated potassium levels can cause increased bowel motility and may lead to gastrointestinal symptoms like diarrhea and cramping. Therefore, decreased bowel motility would not be an expected finding in this case.

A. "Turn on fans in the facility to circulate air." B. "Open the fireplace dampers in the day room." C. "Cover the electrical outlets with wet towels." D. "Move clients to a room above ground with few windows."

Correct Answer is D

Explanation

A. "Turn on fans in the facility to circulate air." Fans should not be turned on during a chemical disaster because they can spread contaminants throughout the facility, increasing exposure to toxic substances.
B. "Open the fireplace dampers in the day room." Opening fireplace dampers can allow contaminated air to enter the facility, increasing the risk of exposure. Sealing off potential entry points for hazardous chemicals is a priority in these situations.
C. "Cover the electrical outlets with wet towels." While sealing gaps and vents can help reduce chemical exposure, using wet towels over electrical outlets is not an effective protective measure. Instead, doors, windows, and ventilation systems should be sealed as much as possible to prevent outside air from entering.
D. "Move clients to a room above ground with few windows." In an external chemical disaster, sheltering in place is essential. A room above ground is preferable because many chemicals are heavier than air and can accumulate in lower levels. Selecting a space with few windows helps minimize exposure by reducing potential entry points for contaminants.

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Exhibits Which of the following findings requires further action by the nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L (3.5 to 5 mEq/L). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

A nurse is assisting with the admission of a client to the labor and delivery unit. Exhibits A nurse is reinforcing teaching to the client about the labor process. Select the 4 statements the nurse should make.

A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?

The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

A nurse is assisting in the care of a client. Exhibits Which of the following interventions should the nurse plan to implement? Select all that apply.

A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.