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. For a patient with GERD (gastroesophageal reflux disease), which dietary advice is most appropriate?

Correct answer: B

Rationale: Avoiding fatty foods can help reduce the symptoms of GERD.

3. Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?

Correct answer: D

Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.

4. You are on duty in the medical ward. You were asked to check the narcotics cabinet. You found out that what is on record does not tally with the drugs used. What will you do first?

Correct answer: C

Rationale: In this situation, the first step should be to report the matter to your supervisor. It is essential to notify the appropriate authority immediately to address the discrepancy in the narcotics cabinet. Choice A is not the first step as reporting to the nursing director should follow after informing the supervisor. Keeping the findings to yourself (Choice B) is not appropriate as it may jeopardize patient safety and is against ethical standards. While finding out which patient received narcotics (Choice D) is important, it is not the immediate action to take in this scenario.

5. What side effect is commonly associated with ECT?

Correct answer: A

Rationale: The correct answer is A, as Electroconvulsive Therapy (ECT) is commonly associated with side effects such as transient loss of memory, confusion, and disorientation. While nausea and vomiting (Choice B) can occur, they are not as common as the memory-related side effects. Fractures (Choice C) are unlikely unless a mishap occurs during the procedure. Hypertension and increased heart rate (Choice D) might occur during the procedure due to the physiological stress of the treatment, but these are not the most commonly associated side effects. The rationale provided did not effectively explain this, so it's important to note that ECT is a procedure often used for severe depression and other mental illnesses, and understanding its side effects is crucial for patient safety and effective care.

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