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Learn NCLEX PN Questions with Rationale 109th Edition
1. A nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which of the following does the nurse document in the plan as the priority nursing intervention for this client?
A. Monitor apical pulse rate
B. Monitor temperature
C. Monitor urine output
D. Monitor blood pressure
Answer: C. Monitor urine output
Rationale: The most common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client’s urine output to determine whether this complication is occurring. Options 1, 2, and 4 are also components of the plan, but option 3 clearly identifies the priority intervention for this type of surgery.
Test-Taking Strategy: To answer this question correctly, you should recall that the pituitary gland is responsible for the production of ADH. This allows you to eliminate each of the incorrect options systematically and directs you to option C. Additionally, note that options 1, 2, and 4 are similar and relate to vital signs. Review the complications of this surgical procedure if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Neurological
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 458-459.
2. A nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which of the following data will not be required by the laboratory for adequate evaluation of the specimen?
A. The date and time the specimen was drawn
B. A list of client allergies
C. Any supplemental oxygen the client is receiving
D. The client’s temperature
Answer: B. A list of client allergies
Rationale: An ABG requisition usually contains information about the date and time the specimen was drawn, the client’s temperature, whether the specimen was drawn on room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. A list of the client’s allergies is not a necessary piece of information required for analysis of the specimen.
Test-Taking Strategy: Note the key word not. This word indicates a false response question and that you need to select the unnecessary data. Review the options from the viewpoint of the relevance of the item to the client’s airway status or oxygen utilization. The client’s allergies do not have a direct bearing on the laboratory results. Review this laboratory test if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Respiratory
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 248-249.
3. A nurse is reinforcing discharge instructions to a client who had a unilateral adrenalectomy. Which of the following will be a component of the instructions?
A. The need for lifelong replacement of all adrenal hormones
B. Instructions about early signs of a wound infection
C. The reason for maintaining a diabetic diet
D. Instruction regarding the proper application of an ostomy pouch
Answer: B. Instructions about early signs of a wound infection
Rationale: A client who is undergoing a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Because of the anti-inflammatory properties of corticosteroids, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. Options 1, 3, and 4 are incorrect instructions.
Test-Taking Strategy: Use the process of elimination. When reading the question, note that only one adrenal gland was removed. Recalling that the hormones from the adrenal glands are needed for proper immune system function will assist in eliminating options 3 and D. From the remaining options, recognizing that one gland can take over the function of two adrenal glands will direct you to option B. Review postoperative teaching points following adrenalectomy if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Adult Health/Endocrine
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877.
4. A nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates that the client understands the discharge instructions?
A. “I need to remove the nasal packing in 1 week.”
B. “I need to cough and deep breathe every 2 hours.”
C. “I can take acetaminophen (Tylenol) if I get a severe headache.”
D. “I need to call the doctor if I develop frequent swallowing or postnasal drip.”
Answer: D. “I need to call the doctor if I develop frequent swallowing or postnasal drip.”
Rationale: The client should report frequent swallowing or postnasal drip after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The surgeon removes the nasal packing, usually after 24 hours. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure (ICP) . The client should also report a severe headache because it could indicate increased ICP.
Test-Taking Strategy: Noting the anatomical location of this surgery will provide the clue that the concern is increased ICP and CSF leakage. Option 1 can be easily eliminated because the physician, not the client, will remove the packing. Options 2 and 3 can be eliminated next. Coughing can cause increased ICP, and a severe headache is an indication of such. Review postoperative teaching following this surgical procedure if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Neurological
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 861.
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