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. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.

B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.

C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.

D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.

A. Clarify misinformation and reorient when confused B. Turn patient every 2 hours C. Ensure bed alarm is on when leaving the patient's room D. Vary schedule to prevent memorization and boredom

Correct Answer is C

Explanation

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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