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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Deep breathing exercises is incorrect. Deep breathing exercises are generally encouraged to help with lung expansion and oxygenation following surgery. However, patients should avoid activities that put pressure on the surgical site, such as bending over or lifting heavy objects, but deep breathing is typically safe unless contraindicated.
B. Bending over to weed the garden is correct. After a transsphenoidal hypophysectomy, patients should avoid bending over or activities that could increase intracranial pressure (ICP), such as gardening, lifting heavy objects, or straining. Bending over can increase pressure in the sinus cavities and may affect the healing process of the surgical site.
C. Drinking plenty of fluids is incorrect. Drinking fluids is generally encouraged after surgery to maintain hydration and promote healing. However, some restrictions may apply if there is a risk for diabetes insipidus or fluid imbalance, but the act of drinking fluids itself is typically recommended.
D. Walking short distances is incorrect. Walking short distances is usually encouraged after surgery to promote circulation and prevent complications like deep vein thrombosis (DVT). As long as the patient is feeling stable, walking can help recovery.
Correct Answer is ["0.14"]
Explanation
Step 1: Identify the known values
- Dose ordered = 2 mcg/kg/day
- Frequency = every 12 hours → 2 doses per day
- Weight = 7 kg
- Concentration available = 0.05 mg/mL
Step 2: Calculate total daily dose in mcg
2 mcg × 7 kg = 14 mcg/day
Step 3: Divide daily dose by 2 to get per dose
14 mcg ÷ 2 = 7 mcg per dose
Step 4: Convert mcg to mg
7 mcg = 0.007 mg
Step 5: Use concentration to calculate mL per dose
0.007 mg ÷ 0.05 mg/mL = 0.14 mL
Answer: 0.14 mL
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