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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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.

• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.

• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.

• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.

• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.

A. "I should limit my intake of leafy green vegetables B. "I may experience loss of taste." C. "I need to be careful when standing up from bed." D. "I should expect some weight loss."

Correct Answer is C

Explanation

A. "I should limit my intake of leafy green vegetables.": Limiting leafy green vegetables is associated with warfarin therapy because of their vitamin K content. It is not relevant to metoprolol, which primarily affects the cardiovascular system and does not interact significantly with dietary vitamin K.

B. "I may experience loss of taste.": Loss of taste is not a common side effect of metoprolol. Metoprolol is more associated with cardiovascular side effects such as bradycardia, hypotension, and dizziness rather than alterations in taste perception.

C. "I need to be careful when standing up from bed.": This is correct because metoprolol can cause orthostatic hypotension, leading to dizziness or lightheadedness upon standing. Clients are advised to rise slowly from a lying or seated position to reduce the risk of falls and fainting.

D. "I should expect some weight loss.": Metoprolol is more commonly associated with weight gain or no significant weight change rather than weight loss. Clients taking beta-blockers sometimes experience fluid retention or a slowed metabolism, leading to modest weight gain.

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

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Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A nurse is reinforcing teaching about the side effects of metoprolol. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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