Nokea
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
- A. Assessing for mouth droop and decreased lateral eye gaze
- B. Assessing for increased middle ear pressure and perforated ear drum
- C. Assessing for gradual onset of conductive hearing loss and nystagmus
- D. Assessing for scar tissue and cerumen obstructing the auditory canal
Correct Answer: A
Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications.
Choices B, C, and D are incorrect:
B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient.
C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively.
D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.
You may also like to solve these questions
The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)
- A. Breech presentation
- B. Ectopic pregnancy
- C. Birth defects
- D. Venous thromboembolism
Correct Answer: A
Rationale: The correct answer is A: Breech presentation. Obesity can lead to a larger fetus, increasing the risk of breech presentation. The rationale is that excess fat can hinder the baby's ability to turn head down. Other choices are incorrect because: B: Ectopic pregnancy is not related to obesity, C: Birth defects can be influenced by maternal health but are not directly linked to obesity, and D: Venous thromboembolism is more associated with immobility and hypercoagulable states rather than obesity.
A 55-year-old man presents at the clinic complaining of erectile dysfunction. The patient has a history of diabetes. The physician orders tadalafil (Cialis) to be taken 1 hour before sexual intercourse. The nurse reviews the patients history prior to instructing the patient on the use of this medication. What disorder will contraindicate the use of tadalafil (Cialis)?
- A. Cataracts
- B. Retinopathy
- C. Hypotension
- D. Diabetic nephropathy
Correct Answer: B
Rationale: The correct answer is B: Retinopathy. Tadalafil (Cialis) is contraindicated in patients with retinopathy due to the potential risk of worsening vision problems. Retinopathy is a serious eye condition commonly associated with diabetes, and using tadalafil can lead to further complications in the eyes. It is crucial for patients with retinopathy to avoid medications that can exacerbate their eye condition.
Incorrect choices:
A: Cataracts - Cataracts do not contraindicate the use of tadalafil. Tadalafil does not have a direct negative impact on cataracts.
C: Hypotension - Hypotension is not a contraindication for tadalafil use. In fact, tadalafil can cause a drop in blood pressure, so it should be used with caution in patients with hypotension.
D: Diabetic nephropathy - Diabetic nephropathy is not a direct contraindication for tadalafil use. Tadalafil is generally
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?
- A. Pruritis (itching)
- B. Nausea and vomiting
- C. Altered glucose metabolism
- D. Confusion
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapy commonly causes gastrointestinal side effects, such as nausea and vomiting, due to its impact on rapidly dividing cells in the digestive tract. This adverse effect can significantly impact a patient's quality of life and adherence to treatment. Pruritis (A), itching, is less common and usually not a primary side effect of chemotherapy. Altered glucose metabolism (C) is a potential effect of some chemotherapeutic agents but is not the most common adverse effect. Confusion (D) is not typically associated with chemotherapy and is more commonly seen with other medications or medical conditions.
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
- A. Utilize a pressure-reducing mattress.
- B. Limit the patients physical activity.
- C. Apply antibiotic ointment to dependent skin surfaces.
- D. Avoid contact with synthetic fabrics.
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
- A. Observe the color of gastric contents.
- B. Verify tube placement before feeding.
- C. Add blue food coloring to the enteral formula.
- D. Run the formula over 12 hours to decrease overload.
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.