A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Position the client supine while in bed.

Change the nasal drip pad as needed.

Encourage frequent brushing of teeth.

Encourage the client to cough every 2 hr following surgery.

Answer and Explanation

The Correct Answer is B

Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.

Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.

Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.

Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.

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Correct Answer is C

Explanation

Choice A reason: Black-colored stools can indicate gastrointestinal bleeding, which is a potential side effect of corticosteroids like betamethasone. It is not considered harmless and should be reported to the healthcare provider immediately.

Choice B reason: A low-potassium diet is not specifically required for clients taking betamethasone. Corticosteroids can cause potassium loss, so it is important to monitor potassium levels, but not necessarily restrict intake unless directed by the healthcare provider.

Choice C reason: The correct answer is c because taking corticosteroids like betamethasone every other day can help reduce the risk of adrenal suppression, a common side effect of long-term corticosteroid use. This dosing schedule allows the adrenal glands to recover and maintain their function.

Choice D reason: Taking betamethasone before bedtime is not specifically recommended for its effectiveness. The dosing schedule should be based on the healthcare provider's instructions and tailored to the client's condition and response to the medication.

A. "I will rest for at least 30 minutes before eating." B. "I will drink plenty of beverages with my meals." C. "I will eat five or six small meals each day." D. "I will increase my intake of protein."

Correct Answer is B

Explanation

Choice A reason: Resting before meals helps reduce fatigue and ensures that the client has the energy to eat, which is important for maintaining nutrition in COPD patients.

Choice B reason: The correct answer is b because drinking plenty of beverages with meals can cause the client to feel full too quickly, reducing their intake of nutrient-dense foods. It is better to drink fluids between meals to ensure adequate nutrition.

Choice C reason: Eating five or six small meals each day helps prevent overeating and reduces the work of breathing, making it easier for COPD clients to maintain adequate nutrition without feeling overly full or short of breath.

Choice D reason: Increasing protein intake is important for COPD clients to maintain muscle mass and strength, which are crucial for respiratory function and overall health.

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A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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