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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Lactulose is a laxative used to treat constipation and hepatic encephalopathy by reducing blood ammonia levels, but it is not effective in lowering serum potassium levels. Therefore, it would not be the appropriate medication for treating hyperkalemia.
Choice B reason: Triamterene is a potassium-sparing diuretic, which means it helps the body retain potassium. Administering Triamterene in a client with high potassium levels (hyperkalemia) would exacerbate the condition rather than improve it. Hence, it is not a suitable choice for this scenario.
Choice C reason: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by binding to potassium in the intestines and facilitating its removal from the body through feces. It effectively reduces serum potassium levels, making it the appropriate medication for a client with hyperkalemia.
Choice D reason: Acetylcysteine is used primarily as a mucolytic agent to break down mucus in the airways or as an antidote for acetaminophen (paracetamol) overdose. It does not have any effect on serum potassium levels and is not suitable for treating hyperkalemia.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: The correct answer is a because orange juice is high in potassium and should be avoided by clients with chronic kidney disease to prevent hyperkalemia, which can lead to serious cardiac complications.
Choice B reason: The correct answer is b because watermelon, although refreshing, is high in potassium and should be limited or avoided by clients with chronic kidney disease to maintain safe potassium levels.
Choice C reason: The correct answer is c because bananas are well-known for their high potassium content and should be avoided by clients with chronic kidney disease to prevent elevated potassium levels in the blood.
Choice D reason: Corn flakes cereal is generally low in potassium and is not a food that needs to be avoided in clients with chronic kidney disease. It can be included in their diet in moderation.
Choice E reason: White rice is also low in potassium and can be safely consumed by clients with chronic kidney disease. It does not pose a significant risk of increasing potassium levels.
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