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 C

Explanation

A. Discarding worksheets containing client information in a wastebasket does not ensure proper disposal of confidential information and could compromise confidentiality.
B. Writing a client's diagnosis on the message board in the client's room could breach confidentiality, as it could potentially be seen by unauthorized individuals.
C. This action protects client confidentiality because it involves discussing sensitive information in a private setting where unauthorized individuals are less likely to overhear. This is an appropriate method of communicating client information during a handoff.
D. While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

A. "An incident report has been completed and sent to risk management." B. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" C. "The client fell because the assistive personnel did not place nonskid slippers on the client." D. "The client does not appear to have any injuries resulting from the fall."

Correct Answer is B

Explanation

A. Incorrect. Mentioning the completion of an incident report is appropriate but not sufficient in explaining the incident.
B. Correct. Documenting the client's own statement about the fall is essential for accuracy and clarity in the medical record.
C. Incorrect. While footwear might contribute to falls, it's important to include the client's own account of the fall in the documentation.
D. Incorrect. While noting the absence of visible injuries is relevant, it's more important to document the circumstances leading to the fall.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.

Correct Answer is C

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is B

Explanation

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 making a follow-up call to a client who has a new prescription for an ACE Inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdown then dropdown

A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?