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. What is the term for a state of disequilibrium wherein a person cannot readily solve a problem or situation using their usual coping mechanisms?

Correct answer: A

Rationale: In psychological terms, a 'Crisis' refers to a state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms. This is different from 'Mental Illness' (Choice C) which is a more general term for a wide range of mental health conditions that affect mood, thinking and behavior. 'Mental Health' (Choice B) is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Finally, 'Stress' (Choice D) is a state of mental or emotional strain or tension resulting from adverse or demanding circumstances, but it does not necessarily disrupt equilibrium to the extent that usual coping mechanisms are ineffective, unlike 'Crisis'.

3. You are to apply a transdermal patch of nitoglycerin to your client. The following are important guidelines to observe EXCEPT:

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.

4. A healthcare provider is admitting a client who practices Hinduism. The healthcare provider should identify that which of the following foods is prohibited according to Hindu dietary practices?

Correct answer: C

Rationale: In Hindu dietary practices, beef is prohibited due to religious beliefs. Hindus consider cows to be sacred animals, and therefore consuming beef is strictly forbidden. Pork, chicken, and seafood are not prohibited in Hindu dietary practices, making choices A, B, and D incorrect.

5. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Correct answer: B

Rationale: In the scenario of severe dysphagia following a CVA, the client may have difficulty swallowing and require alternative nutritional support. Providing supplements via a nasogastric tube allows for the delivery of essential nutrients directly into the stomach, bypassing the swallowing difficulties. NPO (nothing by mouth) until dysphagia subsides may be too restrictive for the client's nutritional needs. Initiation of total parenteral nutrition is usually reserved for cases where enteral feeding is not possible or contraindicated. A soft residue diet may not be suitable for a client experiencing severe dysphagia.

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