The nurse is caring for a client who has undergone a hypophysectomy. Which is the nurse's priority postoperative intervention?
a. Keep the head of the bed flat and the client supine.
b. Instruct the client to cough, turn, and deep breathe hourly.
c. Report clear or yellow drainage from the nose or incision site.
d. Apply petroleum jelly to the client's lips to avoid mouth dryness.
C
A light yellow drainage or a halo effect on the dressing is indicative of a cerebrospinal leak. The client should have the head of the bed elevated after surgery. Although deep breathing is impor-tant postoperatively, coughing should be avoided to prevent cerebrospinal leakage. Although ap-plication of petroleum jelly to the lips will help with mouth dryness, this instruction is not as important as reporting the yellowish drainage.
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