During preoperative teaching to a patient scheduled for a transsphenoidal hypophysectomy for treatment of a pituitary adenoma, the nurse includes which instruction?
Position flat in bed with sandbags at head.
Cough vigorously and deep breathe every 2 hours.
Take replacement growth hormone for a few months.
Report clear drainage from nose.
The Correct Answer is D
A. Position flat in bed with sandbags at head: After a transsphenoidal hypophysectomy, the patient’s head is typically elevated to reduce intracranial pressure and minimize the risk of cerebrospinal fluid (CSF) leakage. Lying flat with sandbags would increase ICP and is contraindicated.
B. Cough vigorously and deep breathe every 2 hours: Forceful coughing and straining increase intracranial pressure and can disrupt the surgical site, leading to CSF leakage or bleeding. Patients are usually instructed to avoid coughing, sneezing, or straining postoperatively.
C. Take replacement growth hormone for a few months: Hormone replacement depends on which pituitary hormones are affected and is individualized. Some patients may require lifelong hormone therapy, not just a few months, and preoperative teaching focuses on surgical precautions rather than post-op medication timing.
D. Report clear drainage from nose: Clear, watery nasal drainage may indicate CSF leak, a serious postoperative complication that increases the risk of meningitis. Prompt reporting allows early assessment and intervention, making this a critical teaching point for patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide for delivery of 100% oxygen to the lungs under pressure: PEEP does not specifically deliver 100% oxygen; rather, it maintains alveolar patency at end expiration. Oxygen concentration is set separately on the ventilator.
B. Prevent the fibrotic infiltration of the lung tissue: PEEP does not directly prevent fibrosis. ARDS-related fibrosis is a long-term complication, and PEEP’s role is primarily mechanical, not anti-fibrotic.
C. Apply positive pressure during inhalation to fully inflate the lungs: Positive pressure during inhalation is provided by the tidal volume or inspiratory pressure, not PEEP. PEEP maintains pressure at the end of exhalation, not during inspiration.
D. Prevent alveolar collapse during expiration: PEEP maintains a baseline positive pressure in the lungs at the end of expiration, preventing alveolar collapse (atelectasis). This improves oxygenation, increases functional residual capacity, and reduces ventilator-induced lung injury in ARDS patients.
Correct Answer is C
Explanation
A. Sitting in the tripod position: Tripod positioning is a common compensatory mechanism in patients with COPD to maximize diaphragmatic expansion and ease breathing. While it indicates respiratory distress, it is an expected adaptive behavior and not immediately life-threatening.
B. O₂ saturation of 91%: An oxygen saturation of 91% is slightly below normal and should be monitored. In COPD patients, target saturations are often 88–92%, so this finding alone may not require urgent intervention if the patient is otherwise stable.
C. Respiratory rate has decreased from 30 to 10 breaths/min: A sudden drop in respiratory rate in a patient previously tachypneic is highly concerning, as it suggests impending respiratory failure or fatigue of the respiratory muscles. This change indicates inadequate ventilation and CO₂ retention, requiring immediate notification to the healthcare provider for urgent intervention.
D. Bilateral lung crackles: Crackles may indicate fluid overload, infection, or pulmonary edema, which are important to monitor and treat. However, in acute respiratory distress, a decreasing respiratory rate represents a more immediate threat to oxygenation and ventilation, making it the highest priority to report.
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