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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I should use my inhaler before exercising." Budesonide is an inhaled corticosteroid used for long-term asthma control, not for immediate prevention of exercise-induced bronchospasm. A short-acting beta-agonist (e.g., albuterol) should be used before exercise to prevent bronchospasm.
B. "I should use my inhaler when I have an asthma attack." Budesonide is not a rescue inhaler. It is used daily to reduce airway inflammation and prevent asthma exacerbations. During an acute asthma attack, a fast-acting bronchodilator, such as albuterol, should be used instead.
C. "I will rinse my mouth and gargle with water after each inhaler treatment." Rinsing the mouth after using an inhaled corticosteroid helps prevent oral candidiasis (thrush), a common side effect of steroid inhalers. This practice also reduces irritation and hoarseness associated with corticosteroid use.
D. "I will take my inhaler treatment before each meal and at bedtime." Budesonide is not taken on a strict schedule tied to meals or bedtime. It is usually administered once or twice daily, as prescribed, to maintain consistent anti-inflammatory effects.

A. The client's extremity should be elevated after the cast is applied. B. The client should keep the cast covered until it is dry. C. The client can shower with the cast after 24 hr. D. The client should use a hair dryer on a warm setting for relieve itching inside the cast.

Correct Answer is A

Explanation

A. The client's extremity should be elevated after the cast is applied. Elevating the extremity above heart level for the first 24 to 48 hours reduces swelling and prevents complications such as compartment syndrome. Ice packs can also be applied to minimize edema.
B. The client should keep the cast covered until it is dry. Covering a wet plaster cast can trap moisture and delay drying, increasing the risk of weakening the cast and skin irritation. Plaster casts should be left uncovered to allow proper air drying.
C. The client can shower with the cast after 24 hr. Plaster casts are not waterproof and should be kept dry at all times. If exposed to water, they can lose their shape and strength, potentially leading to improper healing. A plastic covering should be used when bathing.
D. The client should use a hair dryer on a warm setting to relieve itching inside the cast. Direct heat can weaken the plaster and cause burns. Instead, clients should use a cool hair dryer setting or tap lightly on the cast to manage itching without compromising its integrity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following Instructions should the nurse include in the teaching?

A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?

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 caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Exhibits

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

Select all that apply.