A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take first?
a. Keep the head of the bed flat and the client supine.
b. Instruct the client to cough, turn, and deep breathe.
c. Report clear or light yellow drainage from the nose.
d. Apply petroleum jelly to lips to avoid dryness.
ANS: C
A light yellow drainage or a halo effect on the dressing is indicative of a cerebrospinal fluid leak. The client should have the head of the bed elevated after surgery. Although deep breathing is important postoperatively, coughing should be avoided to prevent cerebrospinal fluid leakage. Although application of petroleum jelly to the lips will help with dryness, this instruction is not as important as reporting the yellowish drainage.
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