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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 B

Explanation

A. Use humor to decrease tension: Humor may not translate well across cultures and languages, and it can lead to miscommunication or offend the client unintentionally. It is better to maintain a respectful, clear, and professional communication style when using an interpreter.

B. Speak in short sentences: Using short, clear sentences helps the interpreter accurately convey the nurse’s message to the client. It allows for better understanding and avoids overwhelming the interpreter with complex information that could get misinterpreted.

C. Speak in third person: Speaking in third person can cause confusion and distance the nurse from the client. It is best to speak directly to the client using first and second person ("I" and "you") so the interaction feels more personal and respectful.

D. Talk directly to the interpreter: The nurse should always speak directly to the client, maintaining eye contact and body language with the client. The interpreter is there to facilitate communication, not to replace the direct interaction between the nurse and the client.

A. “I will empty the pouch every 2 to 3 hours." B. “I will no longer be able to eat nuts." C. “I should expect my stool to be unformed." D. "I will notify my doctor if the stoma starts to look purple."

Correct Answer is D

Explanation

A. "I will empty the pouch every 2 to 3 hours.": While it is important to empty the pouch when it is about one-third to half full, emptying it every 2 to 3 hours is unnecessary unless output is extremely high. Frequent emptying is based on the volume of stool, not strict timing.

B. "I will no longer be able to eat nuts.": Clients with a sigmoid colostomy typically resume a normal diet after healing, including nuts, unless otherwise instructed. Nuts are more commonly restricted after ileostomies due to the risk of obstruction, not sigmoid colostomies.

C. "I should expect my stool to be unformed.": Stool from a sigmoid colostomy is usually formed or semi-formed because it comes from the end of the colon where water absorption has mostly occurred. Unformed stool is more characteristic of ileostomies.

D. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should appear pink to red and moist. A purple, dark, or dusky stoma indicates impaired blood flow or ischemia and requires immediate medical evaluation to prevent serious complications.

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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 using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

Correct Answer is B

Explanation

A nurse is reinforcing teaching for a client who has a new sigmoid colostomy. Which of the following comments by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching to the parents of an infant about the correct use of infant car seats. Which of the following statements by the parents indicates an understanding of the teaching?

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