The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy.
Which intervention is most important for the nurse to include in the patient’s plan of care?

Maintain nasal packing.

Monitor intake and output.

Provide frequent oral care.

Keep the head of the bed elevated to 30 degrees.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Maintaining nasal packing is important after a hypophysectomy, especially if the surgery was performed through the nose (transnasal). However, it is not the most important intervention for a patient with Cushing’s disease in the post-anesthesia care unit (PACU)4.
Choice B rationale
Monitoring intake and output is a standard nursing intervention in the PACU. It helps assess the patient’s fluid balance and kidney function. However, it is not the most important intervention for a patient with Cushing’s disease following a hypophysectomy.
Choice C rationale
Providing frequent oral care is important for patient comfort and prevention of infections, but it is not the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy.

Choice D rationale
Keeping the head of the bed elevated to 30 degrees is the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy. This position helps reduce swelling, decreases the risk of aspiration, and promotes effective breathing and drainage.

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Correct Answer is C

Explanation

Choice A rationale
While taking the blood pressure in the other arm might avoid the spasms, it does not address the underlying cause of the spasms. Therefore, this is not the best action for the nurse to take.
Choice B rationale

Using a different sphygmomanometer would not necessarily prevent the spasms from occurring. The spasms are likely not caused by the equipment itself, but rather a physiological issue within the client.
Choice C rationale
The spasms in the client’s hand and fingers could be a sign of hypocalcemia, a condition where there is not enough calcium in the blood. One of the symptoms of hypocalcemia is muscle spasms or tetany. Therefore, reviewing the client’s serum calcium level would be an appropriate action to take.
Choice D rationale
Administering a PRN antianxiety medication would not address the underlying cause of the spasms. While anxiety can cause muscle tension and spasms, there is no indication in the scenario that anxiety is the cause of this client’s symptoms.

A. Blood glucose level of 90 mg/dL (5 mmol/L). B. Serum creatinine level of 5 mg/dL (442 µmol/L). C. Hemoglobin level of 13 g/dL (130 g/L). D. Potassium level of 4 mEq/L (4 mmol/L).

Correct Answer is B

Explanation

Choice A rationale
A blood glucose level of 90 mg/dL (5 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Choice B rationale
A serum creatinine level of 5 mg/dL (442 µmol/L) is significantly elevated, indicating impaired kidney function. This is a critical lab value that should be reported to the surgeon immediately, as it could impact the patient’s ability to safely undergo surgery and recover postoperatively.

Choice C rationale
A hemoglobin level of 13 g/dL (130 g/L) is within the normal range and would not need to be reported to the surgeon.
Choice D rationale
A potassium level of 4 mEq/L (4 mmol/L) is within the normal range and would not need to be reported to the surgeon.

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The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy. Which intervention is most important for the nurse to include in the patient’s plan of care?

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Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

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The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy.
Which intervention is most important for the nurse to include in the patient’s plan of care?