The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?
Maintain nasal packing.
Keep head of bed at 30°.
Provide frequent mouth care.
Monitor Intake and output.
The Correct Answer is C
A. Maintaining nasal packing may be important post-hypophysectomy to prevent bleeding or cerebrospinal fluid leaks. However, in the context of Cushing's disease, ensuring oral hygiene is
paramount due to increased risk of infection, especially if the patient is on corticosteroid therapy, which suppresses the immune system.
B. Keeping the head of the bed at 30° helps prevent complications such as cerebral edema and increased intracranial pressure. While this is important post-hypophysectomy, it's not specific to Cushing's disease or a priority over oral care.
C. Providing frequent mouth care is crucial in Cushing's disease due to increased cortisol levels leading to immunosuppression and susceptibility to infections. Additionally, glucocorticoid therapy can cause mucosal dryness and ulceration, necessitating meticulous oral hygiene.
D. Monitoring intake and output is essential postoperatively to assess fluid balance and renal function. While important, it's not the priority in this context compared to oral care, especially considering the risk of dehydration due to increased cortisol levels in Cushing's disease.
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Related Questions
Correct Answer is B
Explanation
Rationale for A: Monitoring blood glucose levels is important in septic patients as hyperglycemia can occur due to stress response, and insulin resistance may develop. However, it is not the most critical intervention for immediate stabilization.
Rationale for B: Maintaining strict intake and output is crucial for a patient in septic shock because fluid balance is a key component in managing shock. Accurate measurement of intake and output ensures appropriate fluid resuscitation, which is vital for maintaining blood pressure and organ perfusion.
Rationale for C: Keeping the head of the bed raised 45 degrees can help prevent aspiration, which is particularly important in patients who are at risk of gastrointestinal bleeding or those who are sedated. However, this is not the primary intervention for septic shock management.
Rationale for D: Assessing the warmth of extremities can provide information about peripheral circulation and may indicate the effectiveness of cardiac output. Nevertheless, it is not the most immediate concern in the management of septic shock.
Correct Answer is B
Explanation
A. Respiratory acidosis. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide and increased acidity in the blood. Hyperventilation, as described in the scenario, would not lead to respiratory acidosis.
B. Respiratory alkalosis. Hyperventilation leads to respiratory alkalosis by blowing off excessive carbon dioxide, resulting in decreased levels of carbonic acid and increased blood pH.
C. Metabolic acidosis. Metabolic acidosis results from an accumulation of acids or loss of bicarbonate ions. The scenario does not indicate factors leading to metabolic acidosis.
D. Metabolic alkalosis. Metabolic alkalosis occurs due to excessive loss of acids or increased bicarbonate levels, neither of which is suggested in the scenario.
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