The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy.
Which intervention is most important for the nurse to include in the patient’s plan of care?
Maintain nasal packing.
Monitor intake and output.
Provide frequent oral care.
Keep the head of the bed elevated to 30 degrees.
The Correct Answer is D
Choice A rationale
Maintaining nasal packing is important after a hypophysectomy, especially if the surgery was performed through the nose (transnasal). However, it is not the most important intervention for a patient with Cushing’s disease in the post-anesthesia care unit (PACU)4.
Choice B rationale
Monitoring intake and output is a standard nursing intervention in the PACU. It helps assess the patient’s fluid balance and kidney function. However, it is not the most important intervention for a patient with Cushing’s disease following a hypophysectomy.
Choice C rationale
Providing frequent oral care is important for patient comfort and prevention of infections, but it is not the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy.
Choice D rationale
Keeping the head of the bed elevated to 30 degrees is the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy. This position helps reduce swelling, decreases the risk of aspiration, and promotes effective breathing and drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.
Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.
Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.
Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.
Correct Answer is A
Explanation
Choice A rationale
Initiating a hearing and vision screening program for first graders is an example of secondary prevention. Secondary prevention aims to identify and treat an illness or disease at an early stage, which is exactly what a screening program does.
Choice B rationale
Observing a person with type I diabetes mellitus self-administer a dose of insulin is not an example of secondary prevention. This is more related to disease management, which falls under tertiary prevention.
Choice C rationale
Preparing a presentation on how to prevent the spread of lice is an example of primary prevention, which aims to prevent disease or injury before it ever occurs.
Choice D rationale
Collaborating with a science teacher to prepare a health lesson could be seen as primary prevention if the lesson is about preventing disease, or tertiary prevention if it’s about managing existing conditions.
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