Nursing Elites

1. 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.

2. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

• A. Providing a straw for consumption of liquids
• B. Encouraging larger bites
• C. Placing the client in semi-Fowler's position during meals
• D. Instructing the client to tilt head forward when swallowing

Correct answer: C

Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.

3. A client who is postoperative following a liver transplant and weighs 65 kg. Which of the following actions should the nurse plan to take?

• A. Keep the client NPO for the first week postoperative.
• B. Limit caloric content once the client resumes eating.
• C. Stress the importance of safe food-handling practices.
• D. Decrease foods high in carbohydrates once the client resumes eating.

Correct answer: C

Rationale: After a liver transplant, it is crucial to stress the importance of safe food-handling practices to prevent foodborne illnesses, especially due to the client's altered immune system. Keeping the client NPO for the first week postoperative is not recommended as early nutrition support is essential for recovery. Limiting caloric content once the client resumes eating may not be appropriate as they need adequate nutrition for healing. Decreasing foods high in carbohydrates without a specific indication may lead to inadequate nutrient intake, which is not ideal for the client's recovery.

4. The nurse is correct in performing suctioning when she applies the suction intermittently during:

• A. Insertion of the suction catheter
• B. Withdrawing of the suction catheter
• C. both insertion and withdrawing of the suction catheter
• D. When the suction catheter tip reaches the bifurcation of the trachea

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. To ensure client safety before starting blood transfusions, the following are needed before the procedure can be done EXCEPT:

• A. take baseline vital signs
• B. warm the blood to room temperature for 30 minutes before administering the transfusion
• C. have two nurses verify client identification, blood type, unit number, and expiration date of blood
• D. get consent signed for blood transfusion

Correct answer: D

Rationale: To ensure client safety before starting blood transfusions, taking baseline vital signs, warming the blood to room temperature, and having two nurses verify client identification, blood type, unit number, and expiration date of blood are crucial steps. Consent for blood transfusion is required but is typically obtained before the procedure. The focus before the procedure should be on confirming the right client, blood product, and ensuring the blood is prepared correctly to minimize risks of transfusion reactions.

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