The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

Maintain nasal packing.

Keep head of bed at 30°.

Provide frequent mouth care.

Monitor Intake and output.

Answer and Explanation

The Correct Answer is C

A. Maintaining nasal packing may be important post-hypophysectomy to prevent bleeding or cerebrospinal fluid leaks. However, in the context of Cushing's disease, ensuring oral hygiene is
paramount due to increased risk of infection, especially if the patient is on corticosteroid therapy, which suppresses the immune system.

B. Keeping the head of the bed at 30° helps prevent complications such as cerebral edema and increased intracranial pressure. While this is important post-hypophysectomy, it's not specific to Cushing's disease or a priority over oral care.

C. Providing frequent mouth care is crucial in Cushing's disease due to increased cortisol levels leading to immunosuppression and susceptibility to infections. Additionally, glucocorticoid therapy can cause mucosal dryness and ulceration, necessitating meticulous oral hygiene.

D. Monitoring intake and output is essential postoperatively to assess fluid balance and renal function. While important, it's not the priority in this context compared to oral care, especially considering the risk of dehydration due to increased cortisol levels in Cushing's disease.

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Correct Answer is A

Explanation

A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client is stable with no drainage from the Jackson-Pratt drain, indicating that there is no immediate issue that needs to be addressed. The bulb is compressed, suggesting proper function. Therefore, this client can be safely assessed last.
B. An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.

C. An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.
D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.

A. Verify the prothrombin time (PT). B. Administer prescribed sedative. C. Select a monitor lead with a tall R wave. D. Activate the synchronization mode.

Correct Answer is D

Explanation

A. Verify the prothrombin time (PT).
While it is important to verify coagulation status in patients with atrial fibrillation to ensure they are not at high risk for bleeding, this is not the most critical step immediately prior to
cardioversion. The PT is more relevant if anticoagulation therapy is being managed.

B. Administer prescribed sedative.
Administering a sedative is important for patient comfort during the procedure, but it is not the most critical step that directly affects the success and safety of the cardioversion itself.

C. Select a monitor lead with a tall R wave.
Selecting a monitor lead with a tall R wave helps in accurately synchronizing the cardioversion shock with the R wave, but this is secondary to activating the synchronization mode which is critical to avoid delivering a shock during the vulnerable period of the cardiac cycle.

D. Activate the synchronization mode.
This is the correct answer. The most important action before deploying the current for cardioversion is to ensure the defibrillator is in synchronization mode. Synchronization ensures that the electrical shock is delivered at the correct time during the cardiac cycle, specifically on the R wave of the QRS complex, to avoid inducing ventricular fibrillation. This is crucial for
patient safety.

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The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving report, the nurse can most safely plan to assess which client last?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

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