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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Which of the following treatments is not recommended for a child classified with no dehydration?
- A. Administering 1,000 ml to 1,400 ml within 4 hours
- B. Continuing feeding
- C. Allowing the child to take as much fluid as he wants
- D. Returning the child to the doctor if the condition worsens
Correct Answer: B
Rationale: The correct answer is B. Continuing feeding is a recommended treatment for a child classified with no dehydration. This helps maintain the child's nutritional status and supports recovery. Options A, C, and D are appropriate interventions for a child with no dehydration. Option A ensures adequate fluid intake, option C promotes hydration, and option D ensures appropriate follow-up if the condition worsens.
To prevent baby bottle tooth decay, what should the nurse instruct?
- A. Water
- B. Milk
- C. Iron-fortified formula
- D. Unsweetened fruit juice
Correct Answer: A
Rationale: The correct answer is A: Water. Water is the best choice to prevent baby bottle tooth decay as it does not cause tooth decay and is a good option for bedtime bottles. Milk (choice B) and iron-fortified formula (choice C) contain sugars that can contribute to tooth decay. Unsweetened fruit juice (choice D) also contains natural sugars that can be harmful to the baby's teeth.
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 an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within:
- A. 24 hours
- B. 36 hours
- C. 48 hours
- D. 12 hours
Correct Answer: B
Rationale: In an extreme situation where no other resident or intern is available, if a nurse receives telephone orders, the order has to be correctly written and signed by the physician within 36 hours. This time frame ensures timely documentation and validation of the orders. Choice A (24 hours) is too short a period for busy physicians to fulfill the task. Choice C (48 hours) is too long and delays the incorporation of physician orders into the patient's care plan. Choice D (12 hours) may not provide enough time for the physician to review and sign the order, especially in situations where immediate attention is not required.
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.