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: Feeding the client soft foods is not necessary after cataract surgery. Cataract surgery does not affect the client's ability to eat regular foods, and a normal diet can be resumed unless otherwise instructed by the healthcare provider.
Choice B reason: Positioning the client on the affected side is contraindicated after cataract surgery because it can increase pressure on the eye and disrupt the healing process. Clients are usually advised to avoid sleeping on the side of the operated eye to prevent complications.
Choice C reason: It is not necessary for the client to remain in bed for 3 days following cataract surgery. Clients are encouraged to resume normal activities as tolerated, but they should avoid strenuous activities and heavy lifting to prevent increased intraocular pressure.
Choice D reason: The correct answer is d because wearing dark glasses while outdoors helps protect the eyes from bright light and UV rays, which can cause discomfort and harm the healing eye after cataract surgery.
Correct Answer is A
Explanation
Choice A reason: Russell's traction involves the use of a sling under the knee to apply a pulling force on the femur. This helps in aligning and stabilizing the fractured femur, allowing for proper healing. The sling supports the leg, while weights provide the necessary traction force.
Choice B reason: A cervical halter is used in cervical traction to relieve muscle spasms and align the cervical spine, not in Russell's traction. This type of traction is not related to treating femur fractures.
Choice C reason: A pelvic girdle belt is used in pelvic traction to relieve lower back pain and stabilize pelvic fractures, not in Russell's traction. Russell's traction specifically pertains to femur fractures.
Choice D reason: Skeletal pins are used in skeletal traction, where pins are inserted into the bone to apply direct traction. Russell's traction, however, does not use skeletal pins; it uses a sling and weights to apply traction.
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