A nurse is assisting with the care of a client. Which of the following findings requires further action by the nurse? Select all that apply.

A stapedectomy is a surgical procedure performed to improve conductive hearing loss in clients with otosclerosis by replacing or bypassing the immobilized stapes bone. Postoperative care focuses on monitoring for complications such as inner ear trauma, facial nerve injury, infection, and vestibular dysfunction. Because the surgery involves delicate structures of the middle and inner ear, neurologic and sensory changes must be closely evaluated. Early identification of abnormal findings is essential to prevent permanent deficits. Rationale: A. Lung assessment showing clear bilateral breath sounds does not require further action because it is an expected and normal finding. There is no indication of respiratory compromise or postoperative pulmonary complication. Normal lung sounds suggest adequate ventilation and oxygenation status. B. Pain rating of 5 out of 10 is expected after ear surgery and is not necessarily abnormal if it is controlled with prescribed analgesics. Mild to moderate postoperative pain is common following a stapedectomy due to tissue manipulation. Pain alone, without other concerning signs, does not require urgent intervention. C. Diminished hearing following surgery requires further action because although temporary changes may occur, worsening or unexpected hearing loss may indicate inner ear injury or prosthesis displacement. Postoperative hearing should be monitored closely to differentiate expected transient changes from complications. Significant or progressive hearing loss warrants immediate evaluation. D. Facial nerve assessment showing facial droop requires urgent attention because it may indicate facial nerve injury during surgery. The facial nerve runs close to the middle ear structures and can be affected during a stapedectomy. Facial asymmetry is an abnormal neurologic finding that requires prompt notification of the provider. E. Pupils that are equal, round, and reactive to light are normal postoperative neurological findings and do not require intervention. Stable pupil response indicates intact cranial nerve function and adequate neurological status. No further action is needed for this finding. F. Vertigo requires further evaluation because it may indicate inner ear disturbance or vestibular involvement following stapedectomy. Mild dizziness can be expected postoperatively, but significant vertigo accompanied by nausea may suggest labyrinthine irritation or complication. This finding should be monitored and reported if persistent or worsening.