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 B

Explanation

A. Incorrect. Placing the client in a supine position may impede drainage and is not recommended for a client with a chest tube.
B. Correct. Ensuring that the chest tube drainage system is kept below the level of the client's chest allows for proper drainage of fluid and prevents backflow of drainage into the client's chest.
C. Incorrect. The collection chamber should be emptied as needed to prevent overfilling, which could obstruct drainage.
D. Incorrect. Clamping the chest tube is not indicated for a client with a chest tube set to continuous suction, as it would interfere with the function of the drainage system.

A. 16 lb B. 32 lb C. 24 lb D. 8 lb

Correct Answer is A

Explanation

A. Correct. For a client with a pre-pregnancy BMI of 30.5 (considered obese., an acceptable weight gain during pregnancy is typically around 1120 pounds (59 kg., making 16 pounds an appropriate option within this range.
B. Incorrect. A weight gain of 32 pounds would be considered excessive for a client with a pre-pregnancy BMI of 30.5.
C. Incorrect. A weight gain of 24 pounds might still fall within an acceptable range, but for a client with a pre-pregnancy BMI of 30.5, a weight gain of 16 pounds is a more appropriate option.
D. Incorrect. A weight gain of 8 pounds would likely be insufficient for a client with a pre-pregnancy BMI of 30.5.

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Correct Answer is B

Explanation

A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should include which of the following is an acceptable weight gain for this client?

Correct Answer is A

Explanation

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

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