Question

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Answer 1

Correct Answers:

Monitor intake and output.

Rationale :

🧠 After a hypophysectomy, the most critical risk is disruption of antidiuretic hormone (ADH) secretion due to pituitary manipulation.

🧠 Damage or edema affecting the posterior pituitary can lead to diabetes insipidus, causing excessive urine output and rapid fluid volume loss.

🧠 Careful monitoring of intake and output allows early detection of polyuria, dehydration, and electrolyte imbalance, especially hypernatremia.

🧠 Clients with Cushing’s disease are already vulnerable to fluid and electrolyte instability due to chronic cortisol excess.

🧠 Early identification of abnormal urine output is life-preserving and guides timely intervention such as fluid replacement or desmopressin.

❌Maintain nasal packing

Nasal packing is expected postoperatively but is not the highest priority.

It does not address the immediate risk of hormonal and fluid imbalance.

❌Keep head of bed at 30°

Elevating the head of the bed helps reduce intracranial pressure.

However, it does not prevent the most dangerous postoperative complication.

❌ Provide frequent mouth care

Mouth care improves comfort and oral hygiene.

It is supportive but not critical for early complication detection.

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Answer 2

Correct Answers:

Auscultate lung sounds for wheezing.

Rationale :

suggests an acute hypersensitivity reaction.

🚨 The nurse’s priority is to assess for airway compromise, including bronchospasm and early anaphylaxis.

🚨 Wheezing is an early sign of airway narrowing, which can rapidly progress to respiratory failure.

🚨 Respiratory assessment follows ABCs, making lung auscultation the most urgent intervention.

🚨 Early recognition allows immediate escalation, including oxygen, antihistamines, or epinephrine if needed.

❌ Review the client’s list of drug allergies

Reviewing allergies is important but does not address the immediate threat.

Assessment must occur before retrospective chart review.

❌ Check neurological vital signs

Neurological status is not the primary concern in an acute allergic reaction.

Airway and breathing take precedence.

❌ Document findings in the medical record

Documentation is necessary but never a priority over patient safety.

Assessment and intervention must occur first.

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Answer 3

Correct Answers:

23 to 25 gauge needle.
1 inch needle.

Rationale :

💉: 23 to 25 gauge needle

💉 23–25 gauge needles are appropriate for intramuscular injections in adults, allowing medication to flow effectively without excessive tissue trauma.

💉 This gauge range balances medication viscosity and client comfort.

💉 Using the correct gauge reduces pain and minimizes muscle damage.

💉 It also supports accurate delivery into the muscle tissue.

💉 This choice aligns with standard adult IM administration guidelines.

💉: 1 inch needle

💉 A 1-inch needle is appropriate for an adult weighing 200 lb (90 kg) to ensure the medication reaches the muscle layer.

💉 Adequate needle length prevents accidental subcutaneous injection, which can alter absorption.

💉 Adult muscle mass requires sufficient penetration depth.

💉 Proper needle length improves medication efficacy.

💉 This is especially important for injections into the deltoid or vastus lateralis.

❌ 5/8 inch needle

A 5/8-inch needle is typically used for subcutaneous injections.

It is too short to reliably reach muscle in adults.

❌ Sterile gloves

Sterile gloves are not required for routine IM injections.

Clean technique with non-sterile gloves is sufficient.

❌ 18 to 21 gauge needle

This gauge is too large for standard IM injections.

It increases pain and tissue trauma unnecessarily.

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Answer 4

Correct Answers:

Gastroesophageal reflux disease.

Rationale :

😴 Gastroesophageal reflux disease (GERD) is frequently associated with obstructive sleep apnea due to repeated episodes of upper airway obstruction during sleep.

😴 During apneic episodes, negative intrathoracic pressure increases, which promotes reflux of gastric contents into the esophagus.

😴 OSA also causes frequent arousals and reduced esophageal sphincter tone, further worsening acid reflux, especially at night.

😴 GERD symptoms may aggravate airway inflammation, creating a bidirectional relationship between reflux and sleep apnea severity.

😴 Recognizing GERD as a comorbidity helps reinforce the importance of BiPAP adherence to reduce both respiratory and gastrointestinal complications.

❌Hypotension

OSA is more commonly linked to hypertension, not low blood pressure.

Repeated hypoxia activates the sympathetic nervous system, increasing BP.

❌ Insomnia

Insomnia is a sleep disorder but is not a direct physiologic association of OSA.

OSA primarily causes sleep fragmentation, not difficulty initiating sleep.

❌Weight loss

OSA is strongly associated with obesity and weight gain, not weight loss.

Excess adipose tissue contributes to airway obstruction.

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Answer 5

Correct Answers:

Sputum culture and sensitivity.
White blood cell (WBC) count

Rationale :

🧫 : Sputum culture and sensitivity

🧫 Sputum culture and sensitivity directly identify the causative organism responsible for the respiratory infection.

🧫 Monitoring results helps determine whether the antibiotic is appropriately targeting the pathogen.

🧫 A reduction or eradication of bacterial growth indicates therapeutic effectiveness.

🧫 Sensitivity results guide adjustments if the organism shows antibiotic resistance.

🧫 This lab value is the most specific indicator of infection response in respiratory illness.

🧫: White blood cell (WBC) count

🧫 An elevated WBC count is a common marker of active infection and inflammation.

🧫 As the antibiotic becomes effective, the WBC count should trend downward toward normal levels.

🧫 Monitoring trends is more important than a single value when evaluating response to therapy.

🧫 Persistent leukocytosis may indicate treatment failure or complications.

🧫 This makes WBC count a key systemic indicator of infection resolution.

❌ Red blood cell (RBC) count

RBC count reflects oxygen-carrying capacity, not infection status.

It does not change in response to antibiotic therapy.

❌ Serum potassium

Potassium levels reflect electrolyte balance, not infection resolution.

They are unrelated to antibiotic effectiveness.

❌ Urinalysis

Urinalysis evaluates renal and urinary tract conditions.

It does not assess respiratory infection response.

❌ Blood urea nitrogen (BUN)

BUN reflects kidney function and hydration status.

It is not a marker of antibiotic effectiveness.

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Answer 6

Correct Answers:

Observe aspiration site.

Rationale :

🩸 In a client with thrombocytopenia, the most serious post-procedure risk following a bone marrow biopsy is bleeding due to reduced platelet count.

🩸 Platelets are essential for clot formation, and low levels significantly increase the risk of hemorrhage at invasive sites.

🩸 The biopsy site must be closely monitored for oozing, hematoma formation, or uncontrolled bleeding.

🩸 Early detection of bleeding allows prompt intervention such as direct pressure or provider notification.

🩸 This assessment directly addresses the highest immediate complication related to the client’s laboratory findings.

❌ Measure urinary output

Urinary output reflects renal perfusion and hydration, not bleeding risk.

It is not the priority after a biopsy in a thrombocytopenic client.

❌Assess body temperature

Temperature monitoring helps identify infection, not acute bleeding.

Bleeding poses a more immediate danger in this scenario.

❌Monitor skin elasticity

Skin turgor assesses hydration status.

It does not address the complication related to low platelets.

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Answer 7

Correct Answers:

Stevens-Johnson syndrome.

Rationale :

🚨 Stevens-Johnson syndrome (SJS) is a life-threatening hypersensitivity reaction often triggered by medications such as antibiotics, including azithromycin.

🚨 It is characterized by flu-like symptoms followed by a painful red or purplish rash with blistering.

🚨 Involvement of mucous membranes (mouth, eyes, nose, genitals) is a hallmark feature.

🚨 The condition results from widespread epidermal necrosis and skin sloughing.

🚨 Immediate recognition is critical because SJS can rapidly progress to sepsis, fluid loss, and multi-organ failure.

❌ Pityriasis rosea

Pityriasis rosea causes a mild, self-limiting rash without blistering.

It does not involve mucous membranes or systemic illness.

❌ Anaphylactic reaction

Anaphylaxis presents with airway compromise, hypotension, and urticaria, not blistering skin lesions.

Mucosal blistering is not typical.

❌ Endocarditis

Endocarditis is an infection of the heart valves.

It does not cause widespread blistering rashes with mucosal involvement.

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Answer 8

Correct Answers:

Assist clients on the unit with using incentive spirometer devices.

Rationale :

👥 Incentive spirometer use is a routine, non-invasive task that does not require nursing judgment.

👥 UAPs are trained to assist and remind clients to perform basic respiratory exercises.

👥 This task supports lung expansion and pneumonia prevention without assessment or evaluation.

👥 The RN remains responsible for interpreting effectiveness, not the UAP.

👥 Delegation of this task allows efficient use of team resources while maintaining safe care.

❌ Irrigate a urinary catheter with normal saline

Catheter irrigation requires clinical judgment and sterile technique.

It must be performed by a licensed nurse.

❌ Remove a client’s discontinued nasogastric tube

NG tube removal involves assessment of tolerance and potential complications.

This task is outside the UAP scope.

❌Notify the nurse of a client’s readiness for discharge

Determining discharge readiness requires assessment and clinical decision-making.

This responsibility belongs to licensed nursing staff.

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Answer 9

Correct Answers:

Confirm the date the client last took duloxetine.

Rationale :

⚠️ Phenelzine is a monoamine oxidase inhibitor (MAOI), which carries a high risk for serotonin syndrome if started too soon after other antidepressants.

⚠️ Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) and must be fully cleared from the body before initiating an MAOI.

⚠️ A washout period (usually at least 14 days) is required to prevent life-threatening hypertensive crisis or serotonin toxicity.

⚠️ Confirming the last dose date is the nurse’s most critical safety action before the medication change.

⚠️ This intervention directly prevents a potentially fatal drug interaction, making it the priority.

❌ Review the foods the client typically eats

Dietary teaching is important after phenelzine is started.

It does not address the immediate medication safety risk.

❌ Evaluate if the client has taken phenelzine previously

Past use does not reduce the risk of current drug interactions.

Medication timing is more critical than history.

❌ Assess the client for suicidal ideation

Mental health assessment is always important.

However, medication safety takes priority during an MAOI transition.

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Answer 10

Correct Answers:

Review the need for the UAP to wear a face mask while in close contact with the client.

Rationale :

😷 Influenza requires droplet precautions, which include wearing a surgical face mask during close contact.

😷 Gloves and a gown alone do not protect the mucous membranes from respiratory droplets.

😷 The nurse must intervene to ensure correct PPE use to prevent transmission.

😷 This action supports both client safety and staff protection.

😷 Teaching the correct precaution reinforces infection control standards.

❌ Assign the UAP to another client and assume full care

The UAP can safely assist once proper PPE is used.

Removing the UAP is unnecessary and inefficient.

❌Instruct the UAP to notify the nurse of respiratory changes

This is appropriate but does not correct the immediate PPE issue.

Infection control must be addressed first.

❌Remind the UAP to apply a fitted respirator mask

A fit-tested respirator (N95) is required for airborne precautions, not influenza.

This exceeds the required level of protection.

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QLexNursing

1 :
The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

2 :
Fifteen minutes after receiving sulfamethoxazole-trimethoprim (SMZ-TMP), the client reports a burning sensation over the abdomen, chest, and groin. Which intervention is most important for the nurse to implement?

3 :
The nurse is preparing to administer an IM injection to an adult client who weighs 200 pounds (90 kg). Which equipment is needed for this procedure? Select all that apply.

4 :
The nurse is caring for an older client with severe obstructive sleep apnea (OSA) who is reluctant to wear a bi-level positive airway pressure (BiPAP) mask. Which condition has been identified that is often associated with OSA?

5 :
The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory value(s) should the nurse monitor? Select all that apply.

6 :
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

7 :
A client who is currently receiving azithromycin for an infection reports flu-like symptoms for the past couple of days and a new onset of red and purplish rash with blisters on the skin and mucous membranes of the mouth, nose, eyes, and genitals. Which condition presents with these findings?

8 :
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?

9 :
A client who has been taking duloxetine for several months reports there has been little improvement in symptoms. The healthcare provider changes the prescription to phenelzine. Which action should the nurse take?

10 :
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

QLexNursing

1 : The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

2 : Fifteen minutes after receiving sulfamethoxazole-trimethoprim (SMZ-TMP), the client reports a burning sensation over the abdomen, chest, and groin. Which intervention is most important for the nurse to implement?

3 : The nurse is preparing to administer an IM injection to an adult client who weighs 200 pounds (90 kg). Which equipment is needed for this procedure? Select all that apply.

4 : The nurse is caring for an older client with severe obstructive sleep apnea (OSA) who is reluctant to wear a bi-level positive airway pressure (BiPAP) mask. Which condition has been identified that is often associated with OSA?

5 : The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory value(s) should the nurse monitor? Select all that apply.

6 : A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

7 : A client who is currently receiving azithromycin for an infection reports flu-like symptoms for the past couple of days and a new onset of red and purplish rash with blisters on the skin and mucous membranes of the mouth, nose, eyes, and genitals. Which condition presents with these findings?

8 : The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?

9 : A client who has been taking duloxetine for several months reports there has been little improvement in symptoms. The healthcare provider changes the prescription to phenelzine. Which action should the nurse take?

10 : A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

1 :
The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

2 :
Fifteen minutes after receiving sulfamethoxazole-trimethoprim (SMZ-TMP), the client reports a burning sensation over the abdomen, chest, and groin. Which intervention is most important for the nurse to implement?

3 :
The nurse is preparing to administer an IM injection to an adult client who weighs 200 pounds (90 kg). Which equipment is needed for this procedure? Select all that apply.

4 :
The nurse is caring for an older client with severe obstructive sleep apnea (OSA) who is reluctant to wear a bi-level positive airway pressure (BiPAP) mask. Which condition has been identified that is often associated with OSA?

5 :
The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory value(s) should the nurse monitor? Select all that apply.

6 :
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

7 :
A client who is currently receiving azithromycin for an infection reports flu-like symptoms for the past couple of days and a new onset of red and purplish rash with blisters on the skin and mucous membranes of the mouth, nose, eyes, and genitals. Which condition presents with these findings?

8 :
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?

9 :
A client who has been taking duloxetine for several months reports there has been little improvement in symptoms. The healthcare provider changes the prescription to phenelzine. Which action should the nurse take?

10 :
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?