Nurses' Notes Preoperative 0730:

The client is scheduled for a left stapedectomy.

Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical.

Mucous membranes show color expected for the client's skin tone and moisture.

Speech clear.

Skin warm and dry. Lungs clear bilaterally.

Apical heart rate regular at 78/min. Postoperative

1230:

Pupils were 3 mm, equal, and reactive to light.

Smile asymmetrical. Mucous membranes pink. Speech hoarse.

Client with left facial droop Skin warm and dry.

The client reports vertigo and nausea.

Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min.

The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery.

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

A. Cottage cheese is a dairy product that is not particularly high in fiber and might not effectively help with constipation.
B. Puffed rice cereal is often low in fiber and might not be the best choice to address constipation.
C. While tomato juice can have some benefits, it is not a high-fiber choice to help alleviate constipation.
D. Correct. Bran muffins are a good source of dietary fiber, which can help promote regular bowel movements and relieve constipation.

The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back may indicate supine hypotensive syndrome. This condition can occur during pregnancy when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and causing a drop in blood pressure.

Positioning the client on their left side helps relieve the pressure on the inferior vena cava and improves blood flow. This position allows for optimal circulation and helps alleviate the symptoms associated with supine hypotensive syndrome.

Checking the client's temperature is not necessary in this situation as the symptoms described are not typically associated with a fever. The priority is addressing the client's symptoms related to supine hypotensive syndrome.

Instructing the client to take a brisk walk is not recommended as it may exacerbate their symptoms. Walking increases physical exertion and could further decrease blood flow to the heart.

Providing the client with a glass of orange juice may be helpful if the symptoms were related to low blood sugar (hypoglycemia). However, in this case, the symptoms are more consistent with supine hypotensive syndrome. The priority is to reposition the client to improve blood flow and relieve symptoms. If the client continues to experience symptoms or if there are concerns about low blood sugar, further assessment and appropriate interventions should be implemented.