A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

"I must restrict my fluid intake."

"I must avoid deep breathing exercises."

"I must lie flat for 48 hours after surgery."

"I must avoid blowing my nose and bending at the waist."

Answer and Explanation

The Correct Answer is D

A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.

B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.

C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.

D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.

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Correct Answer is A

Explanation

A. Injecting insulin into the abdominal area is appropriate as it is one of the preferred sites for insulin administration due to its consistent absorption.

B. Blood sugar readings should be taken before meals, not after, to determine the need for insulin and to manage blood glucose levels effectively.

C. Insulin does not allow for unrestricted consumption of high-sugar foods like ice cream; instead, a balanced diet is important to maintain stable blood glucose levels.

D. While weight reduction can help manage diabetes, it does not inherently cause hypoglycemia unless the client is taking insulin or other medications that lower blood glucose.

A. Keep the drainage system below the level of the client's chest at all times. B. Clamp the chest tube prior to transferring the client to a wheelchair. C. Disconnect the chest tube from the drainage system during transport. D. Empty the collection chamber prior to transport.

Correct Answer is A

Explanation

A. It is essential to keep the drainage system below the level of the client's chest to prevent backflow of fluid into the pleural space, which could lead to complications such as a pneumothorax.

B. Clamping the chest tube is generally not recommended during transport because it can lead to a buildup of pressure in the pleural space, increasing the risk of a tension pneumothorax.

C. Disconnecting the chest tube from the drainage system is not advisable, as this could lead to air entering the pleural space, causing a pneumothorax.

D. Emptying the collection chamber is not necessary prior to transport, and it could lead to inaccurate measurement of fluid output. The focus should be on ensuring that the system remains intact and below chest level during transport.

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A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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