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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Moist mucous membranes would indicate adequate hydration, which is not typically seen in diabetes insipidus.
B. Bounding peripheral pulses are associated with conditions of fluid overload, not diabetes insipidus.
C. Poor skin turgor is a sign of dehydration, which is a common finding in diabetes insipidus due to excessive urine output leading to significant fluid loss.
D. Bradycardia is not typically associated with diabetes insipidus; tachycardia might be seen due to dehydration and hypovolemia.
Correct Answer is ["1370"]
Explanation
To calculate the total output of the client, the nurse would add together all the measured outputs. The client voided 400 mL at 1100 and 350 mL at 1430, which totals 750 mL. The closed chest drainage system shows an increase from 155 mL to 175 mL, indicating an output of 20 mL. The NG tube has 575 mL in the drainage container. Additionally, 25 mL was emptied from the Jackson-Pratt drainage tube. Adding these amounts together (750 mL + 20 mL + 575 mL + 25 mL), the total output recorded by the nurse should be 1370 mL.
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