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.
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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Related Questions
Correct Answer is D
Explanation
Choice A reason: Reviewing relaxation techniques can be beneficial for managing anxiety during an asthma attack, but it is not the highest priority in an acute situation.
Choice B reason: Providing immediate rest can help the client conserve energy and reduce the work of breathing, but it does not address the underlying cause of the asthma exacerbation.
Choice C reason: Reminding the client not to try to talk helps reduce the work of breathing, but it is not the most urgent intervention.
Choice D reason: The correct answer is d because administering a short-acting beta-adrenergic medication, such as albuterol, is the highest priority. These medications act quickly to relax the bronchial muscles, reduce bronchospasm, and improve airflow, which is critical in an acute asthma exacerbation.
Correct Answer is A
Explanation
Choice A reason: Russell's traction involves the use of a sling under the knee to apply a pulling force on the femur. This helps in aligning and stabilizing the fractured femur, allowing for proper healing. The sling supports the leg, while weights provide the necessary traction force.
Choice B reason: A cervical halter is used in cervical traction to relieve muscle spasms and align the cervical spine, not in Russell's traction. This type of traction is not related to treating femur fractures.
Choice C reason: A pelvic girdle belt is used in pelvic traction to relieve lower back pain and stabilize pelvic fractures, not in Russell's traction. Russell's traction specifically pertains to femur fractures.
Choice D reason: Skeletal pins are used in skeletal traction, where pins are inserted into the bone to apply direct traction. Russell's traction, however, does not use skeletal pins; it uses a sling and weights to apply traction.
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