in monitoring the patient in pacu the nurse correctly identify that checking the patients vital signs is done every
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Nursing Elites

ATI RN

Nutrition ATI Test

1. In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:

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.

2. Stimulates secretion of bicarbonate ions and digestive enzymes from the pancreas to the small intestine:

Correct answer: D

Rationale: Secretin stimulates the pancreas to release bicarbonate ions to neutralize stomach acid and digestive enzymes into the small intestine.

3. A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct answer is to limit sodium to 2000 mg or less per day. Ascites, which is the abnormal accumulation of fluid in the abdominal cavity, is commonly associated with liver disease. Limiting sodium intake helps manage fluid retention by reducing the fluid accumulation in the abdomen. Choices A, B, and C are incorrect because reducing complex carbohydrates, restricting protein intake, or decreasing caloric intake are not the primary interventions for managing ascites in liver disease.

4. Scurvy is caused by a deficiency of which vitamin?

Correct answer: C

Rationale: Scurvy is caused by a deficiency of vitamin C, not vitamin E. The symptoms of scurvy include spontaneous gingival hemorrhaging, perifollicular petechiae, follicular hyperkeratosis, diarrhea, fatigue, depression, and cessation of bone growth. Vitamin A (Choice A) is important for vision and immune function, Vitamin D (Choice B) is essential for bone health, and Vitamin K (Choice D) is necessary for blood clotting. However, none of these vitamins are associated with scurvy.

5. The counting of sponges is done by the Surgeon together with the:

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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