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What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on?
- A. Condition of patient
- B. Type of anesthesia used
- C. Preference of surgeon
- D. Type of surgical procedure
Correct Answer: A
Rationale: Patient condition dictates the progression through PACU phases, ensuring appropriate care levels.
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The following data are organized according to Gordon’s functional health patterns.
- A. 78-year-old woman
- B. Married, three grown children who all live out of town
- C. Cares for invalid husband in home with help of daily homemaker
- D. Vision corrected with glasses; hearing normal
Correct Answer: A
Rationale: N/A
What are clinical manifestations of insomnia (select all that apply)?
- A. Narcolepsy
- B. Fragmented sleep
- C. Long sleep latency
- D. Morning headache
Correct Answer: B
Rationale: The correct answers are B, C, and F. Fragmented sleep, long sleep latency, and difficulty concentrating are common symptoms of insomnia. Narcolepsy (A) is unrelated, morning headache (D) can occur but is less common, and daytime sleepiness (E) is more typical of sleep apnea.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Cough and deep breathe every 2 hours.
- B. Place the client in contact isolation.
- C. Provide a diet high in protein.
- D. Institute seizure precautions.
Correct Answer: A
Rationale: Encouraging coughing and deep breathing helps prevent pulmonary complications.
Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: C
Rationale: The correct answer is C: Brush the client's teeth with a suction toothbrush every 12 hours. This is crucial in reducing the risk of ventilator-associated pneumonia as it helps prevent the buildup of bacteria in the oral cavity, which can be aspirated into the lungs. Brushing the teeth regularly maintains oral hygiene, decreasing the chances of infection.
A: Positioning the head of the client's bed flat can increase the risk of aspiration and pneumonia.
B: Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.
D: Providing humidity within the ventilator tubing is important for preventing mucous plugs but does not directly address oral hygiene, which is key in preventing pneumonia.