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 D

Explanation

Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.

Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.

Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.

Choice C rationale

Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.

A. Elevate the head of the bed. B. Send the emesis sample to the lab. C. Complete a focused assessment. D. Offer PRN pain medication.

Correct Answer is C,A,B,D

Explanation

Step 1: Complete a focused assessment. The first step in managing a patient with abdominal pain and distention, vomiting, and constipation is to perform a focused assessment. This includes assessing the patient’s vital signs, pain level, abdominal distention, bowel sounds, and any other relevant physical findings.

Step 2: Elevate the head of the bed. Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited.

Step 3: Send the emesis sample to the lab. Analyzing the vomitus can provide important information about the possible causes of the patient’s symptoms. For example, the presence of blood could suggest a gastrointestinal bleed.

Step 4: Offer PRN pain medication. After the initial assessment and interventions, the nurse should address the patient’s comfort. Pain management is an important part of patient care, but in this scenario, it is not the highest priority.

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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

Correct Answer is D

Explanation

Correct Answer is C,A,B,D

Explanation

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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?