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
Monitoring the patient’s blood pressure every 1 hour for 2 hours after paracentesis may not be sufficient. Paracentesis is a procedure to remove fluid that has accumulated in the abdominal cavity (a condition called ascites). This is a common problem in people with certain diseases, including liver and kidney disease. Changes in blood pressure can occur rapidly after this procedure, so more frequent monitoring is needed immediately after the procedure.
Choice B rationale
Monitoring the patient’s blood pressure every 5 minutes for one hour after paracentesis may be too frequent and could cause unnecessary stress for the patient. It is important to balance the need for monitoring with the patient’s comfort and well-being.
Choice C rationale
Monitoring the patient’s blood pressure every 15 minutes for one hour, then every 1 hour for 2 hours after paracentesis is a good schedule. This allows for close monitoring immediately after the procedure, when complications are most likely to occur. It then allows for continued monitoring as the patient stabilizes.
Choice D rationale
Monitoring the patient’s blood pressure every 5 minutes for 30 minutes, then every 4 hours thereafter may not provide enough monitoring in the immediate post-procedure period. While it is important to continue monitoring, the first few hours after the procedure are a critical time when complications are most likely to occur.

A. Reduced level of pain B. Improved visual acuity C. Full volume of pedal pulses D. Granulating tissue in foot ulcer . .

Correct Answer is A

Explanation

Choice A rationale
Pregabalin is a medication used to treat nerve pain, particularly in conditions like diabetic peripheral neuropathy. A reduced level of pain would indicate that the medication is effective.
Choice B rationale
Improved visual acuity is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect vision.
Choice C rationale
Full volume of pedal pulses is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect circulation.
Choice D rationale
Granulating tissue in a foot ulcer is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect wound healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

Correct Answer is C

Explanation

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products. The child has a chemical smell on their hands, face, and clothes. After ensuring the airway is patent, which action should the nurse take first?

A client who weighs 176 pounds is prescribed enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in a 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

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A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

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?