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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Free Nursing Study Resources

Correct Answer is ["3"]

Explanation

To administer the correct dose of clonidine, which is 0.3 mg, the nurse would need to calculate the number of 0.1 mg tablets required. Since each tablet contains 0.1 mg of clonidine, the nurse would need three tablets to make up the total dose of 0.3 mg. Therefore, the nurse should administer three tablets per dose to the patient.

A. Drug dependence B. Cardiac rhythm C. Pulse oximetry D. Pain level

Correct Answer is C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

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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 nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The amount available is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Correct Answer is C

Explanation

The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

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