Nokea
The nurse on the postsurgical unit received a client who was transferred from the post-anesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client's discharge at which point during the hospitalization?
- A. Is admitted to the surgical unit
- B. Is transferred from the PACU to the postsurgical unit
- C. Is able to perform activities of daily living independently
- D. Has been assessed by the healthcare provider for the first time after surgery
Correct Answer: A
Rationale: Discharge planning should begin as soon as the patient is admitted to the surgical unit to ensure a smooth transition. It is important to start early to address any potential barriers to discharge, coordinate resources, and provide adequate education and support. Choices B, C, and D are not the appropriate points to start discharge planning as they do not mark the beginning of the hospitalization phase related to the surgical unit.
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During a physical assessment of a newborn, what finding should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct Answer: A
Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.
The nurse is caring for a client recovering from intestinal surgery. Which assessment finding would require immediate intervention?
- A. Presence of thin pink drainage in the Jackson Pratt drain
- B. Guarding when the nurse touches the abdomen
- C. Tenderness around the surgical site during palpation
- D. Complaints of chills and feeling feverish
Correct Answer: D
Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.
How long is the Practical Nurse Course training program conducted in phases for?
- A. 46 weeks
- B. 18 months
- C. 6 weeks
- D. 52 weeks
Correct Answer: D
Rationale: The correct answer is D: 52 weeks. The Practical Nurse Course is conducted over a period of 52 weeks. This duration allows for a comprehensive training program that covers all necessary aspects of practical nursing. Choices A, B, and C are incorrect because they do not reflect the specific length of time associated with the Practical Nurse Course.
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?
- A. Call a code immediately
- B. Assess the client for a pulse
- C. Begin chest compressions
- D. Continue to monitor the client
Correct Answer: B
Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions. Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.
A patient with a history of gout should avoid which type of food?
- A. Red meat
- B. Chicken
- C. Fish
- D. Dairy
Correct Answer: A
Rationale: The correct answer is A: Red meat. Red meat is high in purines, which can exacerbate gout attacks. Gout is a form of arthritis that occurs when high levels of uric acid in the blood lead to the formation of urate crystals in the joints. Purine-rich foods can increase uric acid levels, leading to gout symptoms. Chicken and fish are lower in purines compared to red meat, making them better choices for individuals with gout. Dairy products are generally considered safe for gout patients and may even have a protective effect against gout.