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A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position?
- A. To promote respiratory effort
- B. To reduce pressure on the sella turcica
- C. To prevent acidosis
- D. To promote oxygenation
Correct Answer: B
Rationale: Elevating the head 30 degrees reduces pressure on the sella turcica, minimizing the risk of cerebrospinal fluid leakage post-hypophysectomy.
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Before the client is discharged, the physician orders lypressin (Diapid) to be administered p.r.n. When instructing the client about how to take this drug at home, the nurse tells the client to administer the drug when experiencing which sign or symptom?
- A. Increased thirst
- B. Onset of a headache
- C. Dark yellow urine
- D. A runny nose
Correct Answer: A
Rationale: Increased thirst is a symptom of diabetes insipidus indicating the need for lypressin to control fluid loss.
If the following foods are available, which one should the nurse recommend?
- A. Cheddar cheese
- B. Raw carrots
- C. Canned fruit
Correct Answer: A
Rationale: Cheddar cheese is high in sodium, which is beneficial for clients with Addison's disease to replace sodium loss.
Which techniques are correct when using an electronic and the patient's capillary blood glucose level? Select all that apply.
- A. Clean the client's finger with povidone-iodine (Betadine).
- B. Take a set of vital signs before the test.
- C. Pierce the central pad of the client's finger.
- D. Apply a large drop of blood to a test strip or area.
- E. Don gloves before piercing the client's finger.
- F. Perform a quality control before the test.
Correct Answer: C,E,F
Rationale: Correct techniques include piercing the finger pad, wearing gloves, and performing quality control for accurate glucometer readings.
The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement?
- A. Increase the regular insulin IV drip.
- B. Check the client's urine for ketones.
- C. Provide the client with a therapeutic diabetic meal.
- D. Notify the HCP to obtain an order to decrease insulin.
Correct Answer: D
Rationale: A glucose drop from 780 to 300 mg/dL requires HCP notification to adjust insulin, preventing hypoglycemia. Increasing insulin, checking ketones, or meals are inappropriate.
The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first?
- A. Assess the eyes using an ophthalmoscope.
- B. Tell the client to keep the eyes closed.
- C. Notify the health-care provider (HCP).
- D. Call the Rapid Response Team (RRT).
Correct Answer: C
Rationale: A curtain-like vision loss suggests retinal detachment, a diabetic complication requiring urgent HCP notification. Ophthalmoscopy, closing eyes, or RRT are inappropriate first steps.