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.

Vertigo

Facial nerve assessment

Pupils

Pain rating

Diminished hearing

Lung assessment

Answer and Explanation

Correct Answer : B,E

A.   Vertigo is common after inner ear surgery like stapedectomy and can be related to changes in the inner ear. It should be monitored, but it's not an immediate concern unless severe.
B.   Correct. A change in facial symmetry (left facial droop) is indicative of potential facial nerve dysfunction, which requires immediate attention.
C.   Pupils are reactive to light, and their size is within the expected range, indicating normal pupillary function.
D.   A pain rating of 5 on a scale of 0 to 10 indicates moderate pain. While it requires attention, it's not a critical concern.
E.   Correct. Diminished hearing following ear surgery is an expected finding, but the nurse should assess the degree and type of hearing loss and communicate this to the healthcare provider.
F. Lung assessment is important but does not require immediate action based on the given information.

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Correct Answer is D

Explanation

A. While monitoring oxygen saturation is important, ensuring an open airway takes priority.
B. Administering oxygen is important, but ensuring an open airway is the initial priority.
C. Checking the pulse rate is important, but ensuring an open airway is the initial priority.
D. Correct. Establishing a patent airway is the most critical action for a client with compromised breathing and cyanosis.

A. Wear shoes with rubber soles. B. Conduct change of shift reports near the clients' rooms. C. Open curtains between clients in semi-private rooms. D. Turn on overhead lights briefly when checking IV lines.

Correct Answer is A

Explanation

The correct answer is choice a. Wear shoes with rubber soles.

Choice A rationale:

Wear shoes with rubber soles () - Quiet footwear minimizes noise disruption during sleep hours, promoting a better sleep environment.

Choice B rationale:

Conduct change of shift reports near the clients’ rooms () - Conducting reports near rooms creates noise and disrupts sleep. It’s best done in designated areas away from patients.

Choice C rationale:

Open curtains between clients in semi-private rooms () - Privacy and individual light control are crucial for sleep. Open curtains can disrupt a client’s sleep cycle.

Choice D rationale:

Turn on overhead lights briefly when checking IV lines () - Bright lights suppress melatonin production, a hormone vital for sleep. Using alternative light sources or dimmed lighting minimizes sleep disruption.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Correct Answer is D

Explanation

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer?

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

A nurse is assisting in the care of a newly admitted client. Which of the following findings should the nurse report immediately to the provider? Select all that apply.

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client in an outpatient provider's office. Exhibits The nurse should identify that the client is at risk of developing dropdown and may require further dropdown.