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 D

Explanation

Choice A reason: An apical pulse rate different than the radial pulse rate is known as a pulse deficit, which can indicate atrial fibrillation or other cardiac arrhythmias, but it is not related to paradoxical blood pressure or constrictive pericarditis.

Choice B reason: An increase in heart rate by 20% when standing is indicative of orthostatic hypotension, not paradoxical blood pressure. This condition involves a drop in blood pressure upon standing, leading to a compensatory increase in heart rate.

Choice C reason: A drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position is another indicator of orthostatic hypotension, not paradoxical blood pressure.

Choice D reason: The correct answer is d because a drop in systolic BP of more than 10 mm Hg on inspiration, known as pulsus paradoxus, is a characteristic finding in constrictive pericarditis. This occurs due to the impaired filling of the heart during inspiration, leading to a significant drop in systolic blood pressure.

A. Place tissue soiled with respiratory secretions in a paper bag for later disposal. B. Provide samples for sputum cultures every 6 weeks. C. Consume alcohol in moderation while taking antituberculosis medications. D. Wear a mask while out or around crowds of people.

Correct Answer is D

Explanation

Choice A reason: Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not an appropriate infection control measure. Used tissues should be disposed of immediately in a proper waste receptacle to prevent the spread of tuberculosis bacteria.

Choice B reason: Sputum cultures should be provided more frequently than every 6 weeks to monitor the effectiveness of the treatment and to confirm when the client is no longer infectious. Monthly cultures are typically recommended until the patient shows no signs of active infection.

Choice C reason: Consuming alcohol in moderation while taking antituberculosis medications is not advised. Alcohol can interfere with the effectiveness of the medications and may also exacerbate potential side effects, such as liver toxicity, especially with medications like isoniazid and rifampin.

Choice D reason: The correct answer is d because wearing a mask while out or around crowds of people helps prevent the spread of tuberculosis. TB is an airborne disease, and wearing a mask reduces the risk of transmitting the infection to others.

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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

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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