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Which of the following findings requires further action by the nurse? Select all that apply.

Lung assessment

Vertigo

Facial nerve assessment

Pain rating

Diminished hearing

Pupils

Answer and Explanation

Correct Answer : B,C,D,E

Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

request a prescription for an increase in statin medication: Although the client's total cholesterol is elevated at 230 mg/dL, adjusting lipid management is not the immediate priority during an acute chest pain episode. The immediate focus should be stabilizing airway, breathing, and circulation.
prepare the client for cardiac catheterization: Cardiac catheterization may ultimately be needed to assess coronary artery blockages, but before this, the client must be stabilized with oxygen and medications to control chest pain and improve oxygenation.
administer oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation dropped to 92% on room air, which is low for someone experiencing chest pain and possible myocardial ischemia. Administering supplemental oxygen improves myocardial oxygen supply and reduces cardiac workload, addressing airway and breathing priorities.
check a STAT cardiac troponin: The client’s initial troponin level was normal, but troponin can take several hours to rise after myocardial injury. While monitoring serial troponins is important, managing oxygenation and chest pain relief takes precedence right now.
administer sublingual nitroglycerin: After ensuring oxygenation, sublingual nitroglycerin should be administered to relieve chest pain by dilating coronary arteries and decreasing myocardial oxygen demand. It helps reduce ischemia and may prevent further cardiac injury.
request a prescription for a beta-blocker: Beta-blockers help control heart rate and blood pressure but are not the immediate first-line response for active chest pain and oxygen desaturation. Oxygen and nitroglycerin must be prioritized first to address the acute ischemic event.

A. Disposes of contaminated sheets in a linen bag B. Wears clean gloves when performing oral hygiene C. Empties the sharps container when it is full D. Wears an N95 mask when bathing a client who has Clostridium difficile

Correct Answer is B

Explanation

A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.

B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.

C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.

D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.

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Which of the following findings requires further action by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Complete the following sentence by using the lists of options. After notifying the provider, the nurse should first ______ and then _______

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Correct Answer is B

Explanation

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