A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?
Position the client supine while in bed.
Change the nasal drip pad as needed.
Encourage frequent brushing of teeth.
Encourage the client to cough every 2 hr following surgery.
The Correct Answer is B
Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.
Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.
Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.
Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Emptying the collection chamber every 4 hours is unnecessary and can increase the risk of introducing infection. The chamber should be emptied as needed based on the volume of drainage.
Choice B reason: Stripping the chest tube, which involves squeezing and releasing sections of the tube to move clots, is not recommended as it can create high negative pressure and cause damage to the lung tissue.
Choice C reason: Pinning the chest tube to the client’s gown can lead to accidental dislodgement. The chest tube should be secured appropriately without tension.
Choice D reason: The correct answer is d because taping the connections on the client’s chest tube ensures that the system remains airtight and prevents air leaks, which is essential for effective functioning of the chest tube and prevention of pneumothorax recurrence.
Correct Answer is C
Explanation
Choice A reason: Stating that "This type of surgery is very easy and should not cause a major disruption in your activities" minimizes the client's concerns and may not be accurate for every individual. Each person's experience with surgery and recovery is unique, and it is important to acknowledge and address the client's specific concerns and reasons for delaying the surgery.
Choice B reason: Saying "Most women don't have any problems during their recovery" is a generalization that may not apply to every client. It does not address the client's individual fears or concerns and may come across as dismissive of their feelings.
Choice C reason: The correct answer is c because asking, "Can you tell me your reasons for delaying the surgery?" shows empathy and allows the client to express their concerns. This opens a dialogue where the nurse can provide information, support, and address any specific issues the client may have about the surgery and recovery process.
Choice D reason: Telling the client, "If this happened to one of my family members, I would tell them to go ahead and not wait," inserts the nurse's personal opinion and may not be helpful to the client. It is important to focus on the client's feelings and concerns rather than offering personal anecdotes or advice.
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