The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included?
a. Palpate extremities for edema.
b. Measure urine volume every hour.
c. Check hematocrit every 2 hours for 8 hours.
d. Monitor continuous pulse oximetry for 24 hours.
ANS: B
After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. 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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