A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

"I must restrict my fluid intake."

"I must avoid deep breathing exercises."

"I must lie flat for 48 hours after surgery."

"I must avoid blowing my nose and bending at the waist."

Answer and Explanation

The Correct Answer is D

A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.

B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.

C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.

D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.

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Correct Answer is A

Explanation

A. Airway patency is the highest priority following a thyroidectomy due to the risk of airway obstruction from swelling or hematoma formation near the surgical site. Compromised airway can lead to respiratory distress and requires immediate attention.

B. While monitoring temperature is important for detecting potential infections, it is not the immediate priority.

C. Pain control is important for comfort and recovery, but it is not life-threatening.

D. Urination should be monitored postoperatively, but it is not as critical as ensuring a patent airway.

A. Instruct the client to limit walking episodes. B. Tell the client that this is normal during pregnancy. C. Gather further assessment data D. Instruct the client to elevate the legs consistently throughout the day.

Correct Answer is C

Explanation

A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.

B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.

C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.

D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.

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A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?

Correct Answer is A

Explanation

A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?

Correct Answer is C

Explanation

A nurse is caring for a client receiving hemodialysis. Exhibits A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?

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