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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. In the event of an outdoor chemical disaster, individuals should stay indoors and take shelter rather than exiting the home.
B. Incorrect. Opening the dampers of fireplaces could allow outdoor contaminants to enter the home.
C. Correct. Covering heat registers with plastic and tape can help prevent outdoor chemicals from entering the home through the ventilation system.
D. Incorrect. Turning on ceiling fans and air conditioners could potentially bring outdoor contaminants indoors through the ventilation system.
Correct Answer is D
Explanation
A. The cause of death is typically determined and documented by the attending physician or coroner, not the nurse.
B.While this information might be included in other parts of the medical record prior to the death, it is not required in postmortem documentation.
C. The nurse should verify that advance directives were followed, but the actual copy of the advance directives does not need to be included in the postmortem documentation. These should already be part of the client’s medical record.
D. Documenting the location of the identification tag is important for proper identification of the body after death. This ensures that the body is correctly identified during transfer to the morgue or funeral home.
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