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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Suggesting that the child participate in a team sport to encourage socialization is not the best response. Duchenne muscular dystrophy (DMD) is a progressive disease that causes muscle weakness and loss of muscle mass. Participating in a team sport could be physically challenging for the child and could potentially lead to injury.
Choice B rationale
Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the best response. Swimming is a low-impact exercise that can help maintain muscle strength and flexibility in children with DMD. It also provides an opportunity for socialization.
Choice C rationale
Explaining that the child is too young to understand the risks associated with swimming is not the best response. Children with DMD can participate in swimming with appropriate supervision and safety measures in place.
Choice D rationale
Providing a list of alternative activities that are less likely to cause the child to experience fatigue is not the best response. While it’s important to consider activities that are appropriate for the child’s physical abilities, it’s also important to consider the child’s interests. The child has expressed a desire to continue swimming, and with appropriate supervision, this activity can be beneficial.
Correct Answer is C
Explanation
Choice A rationale
Vegetarian lasagna with cheese and spinach, a tossed green salad with ranch dressing, and fresh fruit is a balanced meal. However, it may not be the best choice for a patient with type 2 diabetes due to the high carbohydrate content in the lasagna and the dressing.
Choice B rationale
Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie is not the best choice for a patient with type 2 diabetes. Fried foods and mashed potatoes are high in carbohydrates and fats, which can raise blood sugar levels.
Choice C rationale
Grilled fish with whole-grain brown rice, steamed broccoli, and a pear poached in red wine is a good choice for a patient with type 2 diabetes. This meal is balanced with lean protein, whole grains, and vegetables, which can help control blood sugar levels.
Choice D rationale
Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake is not the best choice for a patient with type 2 diabetes. Although the hamburger is lean, the whole-wheat bun and angel food cake are high in carbohydrates, which can raise blood sugar levels.
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