The nurse reviews the client's test results.

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

A. Place the client in a room with a high-efficiency particulate air (HEPA) filter. HEPA filtration is used for airborne precautions, such as tuberculosis. MRSA is transmitted through direct contact, so a private room or cohorting with another MRSA-positive client is sufficient.
B. Don gloves prior to assisting the client with brushing their teeth. MRSA is primarily spread via direct contact with infected wounds, secretions, or contaminated surfaces. Wearing gloves when providing personal care helps prevent transmission.
C. Ensure that the negative air pressure is active for the client's room. Negative pressure rooms are necessary for airborne pathogens like tuberculosis or measles. MRSA does not require airborne precautions, so this is not needed.
D. Have the client wear a mask when they are out of their room. A mask is only required if MRSA is present in the respiratory tract and the client has a productive cough. Standard contact precautions, such as hand hygiene and personal protective equipment, are the primary infection control measures.