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. "You shouldn't feel any pain since the local area is anesthetized." B. "Most clients report more discomfort from the preparation than from the procedure itself." C. "You may feel some cramping during the procedure." D. "Don't worry; you won't remember anything about the procedure due to the effects of the medication."

Correct Answer is C

Explanation

Choice A reason: Local anesthesia is not typically used for a colonoscopy. Sedation and analgesia are used to make the client comfortable, but some sensation may still be felt.

Choice B reason: While it is true that many clients find the bowel preparation uncomfortable, this statement does not address the client's concern about pain during the procedure itself.

Choice C reason: The correct answer is c because it is honest and informative. Clients may experience some cramping during a colonoscopy, but it is usually mild and can be managed with sedation and analgesia.

Choice D reason: This statement may be reassuring but is not entirely accurate. While sedation may cause some amnesia, it is important to provide realistic expectations about the procedure and potential sensations.

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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

A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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