Nokea
After bronchoscopy, the nurse's priority is to check which of the following before feeding?
- A. Gag reflex
- B. Wearing off of anesthesia
- C. Swallowing reflex
- D. Peristalsis
Correct Answer: A
Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.
You may also like to solve these questions
While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:
- A. Set and turn on the alarm of the oximeter
- B. Do nothing since there is no identified problem
- C. Cover the fingertip sensor with a towel or bedsheet
- D. Change the location of the sensor every four hours
Correct Answer: B
Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.
In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:
- A. 1 hour
- B. 5 minutes
- C. 15 minutes
- D. 30 minutes
Correct Answer: A
Rationale: Correct Answer: A - Vital signs monitoring in the PACU (Post-Anesthesia Care Unit) is typically done every hour to closely monitor the patient's condition during the immediate postoperative period. This frequency allows the nurse to promptly identify any changes in the patient's vital signs and intervene as necessary. Choice B (5 minutes) is too frequent for routine vital signs monitoring in the PACU and may not allow for a comprehensive assessment of the patient's stability. Choice C (15 minutes) and Choice D (30 minutes) are also not in line with the standard practice of vital signs monitoring in the PACU, which is typically hourly.
Which symptoms are associated with cancer of the colon?
- A. constipation, ascites, and mucus in the stool
- B. diarrhea, heartburn, and eructation
- C. blood in the stools, anemia, and 'pencil-shaped' stools
- D. anorexia, hematemesis, and increased peristalsis
Correct Answer: C
Rationale: The correct symptoms associated with cancer of the colon are blood in the stools, anemia, and 'pencil-shaped' stools. These symptoms are classic indicators of colorectal cancer. Choices A, B, and D do not typically present in colorectal cancer. Constipation, ascites, and mucus in the stool are more commonly associated with other gastrointestinal conditions. Diarrhea, heartburn, and eructation are not typical symptoms of colon cancer. Anorexia, hematemesis, and increased peristalsis are more indicative of other gastrointestinal issues and not specific to colon cancer.
What are sheets/forms that provide an efficient and time-saving way to record information that must be obtained repeatedly at regular and/or short intervals of time? This does not replace progress notes; instead, it records information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc. These are used whenever specific measurements or observations need to be documented repeatedly. What is this?
- A. Nursing Kardex
- B. Graphic Flow Sheets
- C. Discharge Summary
- D. Medicine and Treatment Record
Correct Answer: A
Rationale: The correct answer is A, Nursing Kardex. Nursing Kardex is a tool used for documenting essential patient information that needs to be recorded repeatedly at regular intervals. It includes vital signs, intake and output, treatment details, postoperative care, postpartum care, and diabetic regimen. This tool is efficient and time-saving for healthcare professionals. Choice B, Graphic Flow Sheets, may be used for visual representation of patient data but is not specifically designed for repeated documentation of essential information. Choice C, Discharge Summary, is a document outlining the patient's care and condition at the time of discharge, not for repeated recording of ongoing data. Choice D, Medicine and Treatment Record, focuses more on specific medications and treatments rather than a comprehensive recording of various patient data needed at regular intervals.
What is the most appropriate instruction to provide to the parent of a child who does not like a food item?
- A. The child should not be encouraged to try it again.
- B. The child should be offered a reward if they eat most of the food items.
- C. The child should be offered the item at least 8 times on different occasions.
- D. The child should be encouraged to eat at least 5 bites of the food item.
Correct Answer: C
Rationale: The correct answer is C. Encouraging repeated exposure to the food item can help the child develop a taste for it. Option A is incorrect as it suggests avoiding encouraging the child to try the food again, which may hinder their ability to develop a liking for it. Option B is incorrect as using rewards for eating may not promote a genuine interest in the food item. Option D is incorrect because setting a specific number of bites may create pressure and negativity around mealtime, rather than fostering a positive association with the food.