Nokea
When the nurse prepares the client for the myringotomy, which statement best explains the purpose of the procedure?
- A. A myringotomy prevents permanent hearing loss.
- B. A myringotomy provides a pathway for drainage.
- C. A myringotomy aids in administering medications.
- D. A myringotomy maintains motion of the ear bones.
Correct Answer: B
Rationale: A myringotomy creates an opening for fluid drainage, relieving pressure.
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The nurse is caring for a client who is having silver nitrate dressings. Which lab values should the nurse monitor?
- A. Blood urea nitrogen (BUN)
- B. Blood gases
- C. Complete blood count (CBC)
- D. Serum electrolytes
Correct Answer: D
Rationale: Silver nitrate can cause electrolyte imbalances, particularly hyponatremia and hypokalemia, requiring monitoring of serum electrolytes.
When instilling prescribed medication into the ear of an adult, which is the correct technique for the nurse to use to straighten the ear canal?
- A. Pull the ear upward and backward.
- B. Pull the ear upward and forward.
- C. Pull the ear downward and backward.
Correct Answer: A
Rationale: Pulling the ear upward and backward straightens the adult ear canal.
Which subjective symptom is the client most likely to report to the nurse?
- A. Burning
- B. Pressure
- C. Vertigo
- D. Pain
Correct Answer: C
Rationale: Vertigo is a hallmark symptom of Meniere's disease due to inner ear fluid imbalance.
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
When the nurse reviews the client's health history, which symptom is directly related to the development of cataracts?
- A. Gradual loss of vision
- B. Feeling of fullness within the eye
- C. Ocular pain or discomfort
- D. Flashes of light
Correct Answer: A
Rationale: Cataracts cause a gradual loss of vision due to lens opacity.