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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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: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.
Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.
Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.
Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.
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