The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?

Anticipate a medical prescription for a hearing test

Obtain a culture of the drainage

Remove any foreign body from the ear canal

Obtain a medical prescription for a CT of the skull

Answer and Explanation

The Correct Answer is B

A. A hearing test does not address the infection symptoms and would not be the priority.

B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.

C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.

D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.

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Correct Answer is D

Explanation

A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.

B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.

C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.

D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.

A. Take this medication with food or milk B. Get potassium levels drawn periodically C. Increase intake of green vegetables D. Use salt substitute for cooking

Correct Answer is B

Explanation

A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.

B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.

C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.

D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.

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The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?

Correct Answer is D

Explanation

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

Correct Answer is B

Explanation

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