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.

Answer and Explanation

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 B

Explanation

Choice A reason: Fresh fruits and vegetables can harbor bacteria and other pathogens that pose a significant infection risk to neutropenic clients. It's advisable to avoid these foods unless they are cooked or properly washed and peeled.

Choice B reason: Avoiding crowded places is essential for neutropenic clients because their immune system is weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to infectious agents.

Choice C reason: Participating in gardening is not recommended as it exposes neutropenic clients to soil bacteria and fungi, which can cause infections. Activities should be chosen carefully to minimize infection risk.

Choice D reason: Taking temperature weekly is not adequate for neutropenic clients. Daily temperature monitoring is important for early detection of infections, which can progress rapidly in immunocompromised individuals.

A. "Russell's traction uses a sling under the knee to treat a fracture of the femur." B. "Russell's traction uses a cervical halter to decrease cervical muscle spasms." C. "Russell's traction uses a pelvic girdle belt to decrease lower back pain." D. "Russell's traction uses skeletal pins to stabilize the fracture."

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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