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.

Nursing Test Bank

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Correct Answer is A

Explanation

The correct answer is choicea. Obtain the client’s blood pressure in the other arm.

Choice A rationale:

Obtaining the client’s blood pressure in the other arm is crucial to avoid compromising the arteriovenous fistula. Measuring blood pressure in the arm with the fistula can damage the access site and impair its function.

Choice B rationale:

Encouraging the client to increase fluid intake is not appropriate for clients undergoing hemodialysis, as they often need to restrict fluid intake to prevent fluid overload.

Choice C rationale:

Reinforcing with the client to sleep on the side of the access site is incorrect. Clients should avoid sleeping on the arm with the fistula to prevent compression and potential damage to the access site.

Choice D rationale:

Obtaining the client’s weight is important for monitoring fluid balance, but it is not specific to the care of the arteriovenous fistula.

A. Assists the client to the bathroom every 2 hr B. Locks the wheels on the client's bed C. Raises all four side rails on the client's bed D. Clears furniture from the path leading to the bathroom

Correct Answer is C

Explanation

A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.

B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.

C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.

D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

Correct Answer is A

Explanation

A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is C

Explanation

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A nurse is assisting with the care of a client. Exhibits The client likely suffered from dropdown as evidenced by dropdown

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