Nokea
When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
- A. Amount of food and fluid taken during the last meal before treatment
- B. Respiratory rate, breath sounds, and location of congestion
- C. Teaching the client's relatives to perform the procedure
- D. Doctor's order regarding position restrictions and client's tolerance for lying flat
Correct Answer: B
Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.
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What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
- A. Sensation of taste
- B. Sensation of pressure
- C. Sensation of smell
- D. Urge to defecate
Correct Answer: B
Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.
A patient is on a low-sodium diet. Which food item should the patient avoid?
- A. Fresh fruit
- B. Canned soup
- C. Whole grain bread
- D. Grilled chicken
Correct Answer: B
Rationale: The correct answer is B: Canned soup. Canned soup is commonly high in sodium content, which is not suitable for a patient on a low-sodium diet. Fresh fruit, whole grain bread, and grilled chicken typically have lower sodium levels and can be included in a low-sodium diet. Therefore, the patient should avoid canned soup to adhere to the requirements of a low-sodium diet.
Based on universally-accepted color codes, what color would you expect a tank containing nitrous oxide (laughing gas) to have?
- A. Red
- B. Blue
- C. Green
- D. Orange
Correct Answer: A
Rationale: The correct answer is A: Red. In the medical field, tanks containing nitrous oxide (laughing gas) are typically color-coded with a specific color for easy identification. Nitrous oxide tanks are commonly labeled with a red color code. This color-coding system helps healthcare providers quickly and accurately identify the contents of the tanks, reducing the risk of errors in administering gases to patients. Choices B, C, and D are incorrect because the universally-accepted color for nitrous oxide tanks is red, not blue, green, or orange.
A patient is being discharged with a vitamin K deficiency. What food should the nurse recommend to the patient to include in their diet?
- A. Oranges
- B. Spinach
- C. Fish
- D. Nuts
Correct Answer: B
Rationale: Spinach is an excellent source of vitamin K, which plays a vital role in blood clotting and bone health. Oranges, fish, and nuts do not contain significant amounts of vitamin K, making them less suitable choices to address a vitamin K deficiency. Therefore, the correct recommendation for a patient with a vitamin K deficiency would be to include spinach in their diet to help replenish this essential vitamin.
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.