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Questions 164

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Question 1 of 5

The nurse is caring for a client who underwent a transsphenoidal hypophysectomy to remove a pituitary adenoma. Which of the following interventions should the nurse implement? Select all that apply.

Correct Answer: B,D,E

Rationale: Mouth care prevents infection, neurologic checks monitor for complications (e.g., CSF leak), and avoiding toothbrushing prevents suture disruption. Coughing risks increasing intracranial pressure, and the head of the bed should be elevated to reduce pressure.

Question 2 of 5

The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:

Correct Answer: D

Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.

Question 3 of 5

During the discharge teaching of a client with Buerger's disease, the nurse should teach the client:

Correct Answer: A

Rationale: Exercises to improve vascular return, such as ankle pumps, help manage Buerger's disease by promoting circulation in the extremities.

Question 4 of 5

The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

Correct Answer: C

Rationale: Nephrotoxicity. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

Question 5 of 5

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply.

Correct Answer: A,D,E

Rationale: Tetracycline binds to calcium in dairy, reducing absorption. It can reduce oral contraceptive efficacy, requiring backup methods. Photosensitivity necessitates sunblock. Taking with food or at bedtime is acceptable but not critical teaching.

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