Which safety measure is most important for the nurse to institute for a patient who has Cushing Syndrome?

Using a lift sheet to change the patient's position

Assisting the patient to change positions slowly

Padding the siderails of the patient's bed

Keeping suctioning equipment at the patient's bedside

Answer and Explanation

The Correct Answer is B

A. Using a lift sheet is helpful for preventing injury and ensuring safe handling of the patient, but it is not the most critical safety measure for a patient with Cushing’s syndrome.
B. Assisting the patient to change positions slowly is the most important safety measure for a patient with Cushing’s syndrome. Patients with Cushing’s syndrome often have osteoporosis and a risk of fractures due to prolonged exposure to high cortisol levels, which can lead to weakened bones. Orthostatic hypotension may also occur, so changing positions slowly can prevent falls.
C. Padding the siderails of the bed is typically done for patients at risk of seizures or those with neurological issues, not as a primary concern for patients with Cushing’s syndrome.
D. While keeping suction equipment at the bedside is important for patients at risk of aspiration or respiratory issues, it is not the most critical measure for a patient with Cushing’s syndrome. The most significant concern is the risk of falls and fractures due to bone weakening and potential hypotension.

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Correct Answer is B

Explanation

A. Constant bubbling in the suction-control chamber is normal as it indicates that the suction is active and functioning as intended. The chamber should have steady bubbling when suction is applied.
B. Continuous bubbling in the water-seal chamber is abnormal and indicates a potential air leak. The water-seal chamber should only bubble intermittently with respiratory effort or changes in pressure; constant bubbling suggests that air is being introduced into the system, which could indicate a malfunction or an air leak at the insertion site or along the tubing.
C. Fluid-level fluctuations in the water-seal chamber are normal and should be observed, especially with breathing. The fluid levels will rise with inspiration and fall with expiration, reflecting the changes in pressure within the pleural space.
D. Bloody drainage in the collection chamber is expected immediately after surgery, particularly in the early postoperative period. It may be a sign of surgical site drainage, but if it becomes excessive or persists, further assessment is required. However, a small amount of blood in the collection chamber initially is not abnormal.

A. Exercise safe sex practices. B. Reduce smoking to half a pack/day. C. Alcohol consumption is not a risk factor. D. Refrain from using harsh toothpastes or mouthwashes.

Correct Answer is A

Explanation

A. Exercising safe sex practices, especially in regard to human papillomavirus (HPV), is important because HPV is a known risk factor for head and neck cancers, particularly oropharyngeal cancers. Safe sex practices, including the use of barriers like condoms, can reduce the risk of HPV infection.
B. Reducing smoking to half a pack/day is still a significant risk factor for head and neck cancer. The best approach is to quit smoking completely, as even small amounts of tobacco use increase the risk of cancer.
C. Alcohol consumption is a known risk factor for head and neck cancer, particularly when combined with smoking. The nurse should educate the client to limit alcohol intake or avoid it altogether.
D. Using harsh toothpastes or mouthwashes does not significantly affect the risk of head and neck cancer. However, maintaining good oral hygiene is important for overall health.

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Which safety measure is most important for the nurse to institute for a patient who has Cushing Syndrome?

Nursing Test Bank

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