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 A

Explanation

A. Prepare the client for a chest x-ray to verify catheter placement. A chest x-ray is required after central venous catheter insertion to confirm proper placement before initiating total parenteral nutrition (TPN). Incorrect placement can lead to complications such as pneumothorax, arterial puncture, or catheter malposition, making verification essential for safe administration.
B. Use clean technique when changing the catheter dressing. Central venous catheter dressings require sterile technique, not clean technique, to prevent bloodstream infections. Proper infection control measures, including hand hygiene, chlorhexidine skin antisepsis, and sterile gloves, help minimize the risk of catheter-related bloodstream infections.
C. Verify the amount of TPN solution the client is receiving every 4 hr. TPN is typically monitored continuously, with infusion rates checked at least hourly to ensure proper administration. Regular assessments of fluid balance, glucose levels, and electrolyte status are also necessary to prevent complications such as hyperglycemia or fluid overload.
D. Place the client in Sims' position for catheter insertion. The preferred position for central venous catheter insertion is Trendelenburg or supine, which helps dilate the veins and reduces the risk of air embolism. Sims’ position (lying on the left side with the right knee flexed) is not appropriate for this procedure.

A. Inject 15 units of air into the regular insulin vial. B. Place the cap over the needle. C. Withdraw 10 units of NPH insulin. D. Verify the dosage with another nurse.

Correct Answer is A

Explanation

A. Inject 15 units of air into the regular insulin vial. When mixing NPH and regular insulin, air is first injected into both vials without touching the solution. After injecting air into the NPH vial, the next step is to inject air into the regular insulin vial to maintain proper vial pressure before withdrawing the dose.
B. Place the cap over the needle. Recapping needles increases the risk of needlestick injuries and is not necessary during the insulin preparation process. The needle should remain uncapped until both insulins are drawn and the injection is ready.
C. Withdraw 10 units of NPH insulin. Regular insulin should be drawn first to prevent contamination with NPH insulin. Since NPH is a cloudy suspension and regular insulin is clear, drawing regular insulin first ensures that the short-acting insulin remains unaltered.
D. Verify the dosage with another nurse. While verifying high-risk medications like insulin is important, the appropriate step after injecting air into the NPH vial is to proceed with injecting air into the regular insulin vial before withdrawing any insulin.

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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 assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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Exhibits

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

Select all that apply.