Nokea
Following a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: A CSF leak is a potential complication of transsphenoidal hypophysectomy due to the surgical approach through the sphenoid sinus, requiring careful monitoring.
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On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half the incision has torn apart. The nurse should immediately take what action?
- A. Flush the wound with sterile water.
- B. Apply an abdominal binder.
- C. Cover the wound with a sterile dressing moistened with normal saline.
- D. Apply strips of tape.
Correct Answer: C
Rationale: Covering the wound with a sterile dressing moistened with normal saline protects the open wound from infection and keeps it moist until further medical evaluation. Flushing, applying a binder, or using tape are inappropriate without addressing the dehiscence first. CN: Physiological adaptation; CL: Synthesize
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:
- A. Some melanomas have a familial component and she should seek medical advice.
- B. Her personal risk is low because most melanomas occur at age 60 or later.
- C. Her personal risk is low because melanoma does not have a familial component.
- D. She should not worry because she did not experience severe sunburn as a child.
Correct Answer: A
Rationale: Melanoma can have a familial component, and a family history increases personal risk. Seeking medical advice for screening and risk assessment is appropriate, especially given her sister's diagnosis.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) reduces metabolic demands and supports recovery in viral hepatitis. Increased fluids (B) are supportive but secondary. High-protein diets (C) or avoiding carbohydrates (D) are not indicated for hepatitis management.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
Guaifenesin (Robitussin) 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
Correct Answer: 7.5 mL
Rationale: To calculate the dose: 300 mg ÷ 200 mg/5 mL = 1.5 × 5 mL = 7.5 mL per dose.