A nurse is caring for a client with suspected pheochromocytoma. The nurse recognizes that which of the following is the priority action?

Obtain hourly glucose levels

Prepare client for a CT scan

Request order for serum calcium levels

Monitor Blood Pressure

Answer and Explanation

The Correct Answer is D

A. Monitoring glucose levels may be necessary, as pheochromocytoma can cause hyperglycemia, but it is not the immediate priority.
B. A CT scan may be part of the diagnostic process to locate the adrenal tumor, but the priority is to control blood pressure first due to the risk of severe hypertensive crisis.
C. Serum calcium levels are not directly related to pheochromocytoma and are not a priority action.
D. Monitoring blood pressure is critical, as pheochromocytoma causes episodes of severe hypertension, which can lead to life-threatening complications.

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Correct Answer is B

Explanation

A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.

A. Ensure that the vest supporting the halo device is snug and properly aligned. B. Apply a thick layer of zinc oxide cream around the pin sites. C. Pad the areas of skin breakdown with foam dressing to reduce friction and pressure. D. Loosen the halo device to reduce pressure on the skin.

Correct Answer is C

Explanation

A. While ensuring proper alignment is important, it does not address the existing skin breakdown and irritation.
B. Applying zinc oxide cream may not be appropriate as it can trap moisture, potentially worsening the skin condition around pin sites.
C. Padding the areas of skin breakdown with foam dressing is an appropriate intervention as it can provide cushioning, reduce friction, and protect the skin from further injury.
D. Loosening the halo device could compromise the stabilization it provides and may not effectively address skin integrity issues.

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A nurse is caring for a client with suspected pheochromocytoma. The nurse recognizes that which of the following is the priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has undergone a cataract extraction and during the early postoperative period is complaining of nausea and severe eye pain over the operative site. What should be the initial nursing action?

Correct Answer is B

Explanation

A nurse is providing care for a client with a halo device. The client has developed skin breakdown and irritation around the pin sites. Which intervention is most appropriate for the nurse to implement to prevent further skin complications?

Correct Answer is C

Explanation

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