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The nurse is caring for a patient who has had a transsphenoidal resection of a pituitary tumour. Which of the following nursing actions should be included in the postoperative plan of care?
- A. Monitor urine output every hour.
- B. Palpate extremities for dependent edema.
- C. Check hematocrit hourly for first 12 hours.
- D. Obtain continuous pulse oximetry for 24 hours.
Correct Answer: A
Rationale: After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema and monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.
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The nurse is providing postoperative care for a patient who had a bilateral adrenalectomy. Which assessment information requires the most rapid action by the nurse?
- A. The blood glucose is 8 mmol/L.
- B. The lungs have bibasilar crackles.
- C. The patient's BP is 88/50 mm Hg.
- D. The patient has 5/10 incisional pain.
Correct Answer: C
Rationale: The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.
The nurse is caring for a patient who has an adrenocortical adenoma and hyperaldosteronism. Which of the following actions should the nurse implement?
- A. Provide a potassium-restricted diet.
- B. Monitor the blood pressure every 4 hours.
- C. Evaluate blood glucose level every 4 hours.
- D. Maintain extremities in an elevated position.
Correct Answer: B
Rationale: Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation before surgery. Edema does not usually occur with hyperaldosteronism.
The nurse is admitting a patient with possible syndrome of inappropriate antidiuretic hormone (SIADH) due to a head trauma. Which of the following information obtained by the nurse is most important to communicate rapidly to the health care provider?
- A. The patient complains of dyspnea with activity.
- B. The patient has a urine specific gravity of 1.025.
- C. The patient has a recent weight gain of 5.6 kg.
- D. The patient has a serum sodium level of 119 mmol/L.
Correct Answer: D
Rationale: A serum sodium of less than 120 mmol/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.
The nurse is caring for a patient with acute adrenal insufficiency. Which of the following findings indicate that the prescribed therapies are effective?
- A. Increasing serum sodium levels
- B. Decreasing blood glucose levels
- C. Decreasing serum chloride levels
- D. Increasing serum potassium levels
Correct Answer: A
Rationale: Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.
Which of the following actions should the nurse take first when caring for a patient who has just arrived on the unit after a thyroidectomy?
- A. Check the dressing for bleeding.
- B. Assess respiratory rate and effort.
- C. Take the blood pressure and pulse.
- D. Support the patient's head with pillows.
Correct Answer: B
Rationale: Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post-thyroidectomy but are not as high in priority.