Which of the following are priority nursing assessments related to a client post-op transsphenoidal hypophysectomy for a tumor of the pituitary g (Select All that Apply.)
Monitor for increased intracranial pressure
Monitor incision under the top lip for infection
Assess for signs of deep vein thrombosis (DVT)
Development of meningitis
Assess for signs of cerebrospinal fluid (CSF) leak
Correct Answer : A,B,D,E
A. Monitor for increased intracranial pressure is correct. Following a transsphenoidal hypophysectomy, it is essential to monitor for signs of increased intracranial pressure (ICP) due to the proximity of the surgery to the brain and the risk of complications such as bleeding, swelling, or fluid buildup. Symptoms of increased ICP include headache, nausea, vomiting, and altered level of consciousness.
B. Monitor incision under the top lip for infection is correct. The incision for a transsphenoidal hypophysectomy is typically made under the top lip or at the base of the nose, and it is essential to monitor this site for signs of infection, such as redness, swelling, drainage, or increased pain.
C. Assess for signs of deep vein thrombosis (DVT) is incorrect. Although DVT prevention (e.g., ambulation, use of compression stockings) is important after surgery, monitoring for DVT is not a priority assessment specifically related to a transsphenoidal hypophysectomy. The other assessments are more directly related to potential complications from this specific type of surgery.
D. Development of meningitis is correct. Meningitis is a potential complication after a transsphenoidal hypophysectomy, especially if there is a breach in the nasal cavity or sinus, allowing for infection to spread. Signs of meningitis include fever, nausea, stiff neck, and headache.
E. Assess for signs of cerebrospinal fluid (CSF) leak is correct. A CSF leak is a serious complication of transsphenoidal surgery, as it can occur if the dura is punctured during the procedure. This leads to leakage of cerebrospinal fluid, which may manifest as a clear, watery drainage from the nose, a condition that should be assessed for immediately to prevent further complications like infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Perioperative antibiotics is correct. The benchmark is 100%. Performance was 90.4% in Q1, 88.2% in Q2, and 92.6% in Q3, all of which are below the benchmark, indicating noncompliance.
B. Smoking cessation is correct. The benchmark is 75%. While Q2 reached 100%, Q1 (70.6%) and Q3 (74%) were both below the benchmark, showing inconsistent compliance.
C. Glucose control is correct. The benchmark is 90%. All quarters were below the benchmark: Q1 (75.2%), Q2 (85.5%), and Q3 (82%).
D. Post operative normothermia is correct. The benchmark is 85%. Q1 (69%) fell below the benchmark, although Q2 and Q3 met or exceeded it. Still, any quarter below the benchmark signals an area for improvement.
E. Intraoperative vancomycin is incorrect. The benchmark is 80.2%. While Q1 (75.7%) fell slightly below the benchmark, Q2 (80.5%) and Q3 (92%) met or exceeded it, indicating overall adequate performance and improvement over time.
Correct Answer is D
Explanation
A. Administer an oral potassium supplement is incorrect. Potassium imbalances can cause muscle weakness and cramps, but the client’s symptoms are more likely related to hypocalcemia rather than hypokalemia. Administering potassium without verifying the actual cause of the symptoms could be inappropriate.
B. Request prescription for a relaxant is incorrect. While muscle spasms can be painful, the first priority is to address the underlying cause of the spasms, which in this case is likely hypocalcemia. A muscle relaxant might not address the root cause and could delay appropriate treatment.
C. Check the pedal pulses is incorrect. While checking pedal pulses is important for assessing circulation, the client's symptoms of severe muscle spasms are more indicative of hypocalcemia rather than a circulation issue. The nurse's priority should be to address the electrolyte imbalance.
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