You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

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Question 1 of 5

You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

Correct Answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

Question 2 of 5

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

Correct Answer: D

Rationale: During endotracheal suctioning, the nurse should apply suctioning while withdrawing and gently rotating the catheter 360 degrees for a short period of 0-5 seconds. This brief duration helps minimize the risk of hypoxia and trauma to the airway. Choices A, B, and C suggest longer time periods for suctioning, which can increase the risk of complications such as hypoxia, mucosal damage, and the removal of excess amounts of airway secretions.

Question 3 of 5

What is the purpose of the cuff in a Tracheostomy tube?

Correct Answer: B

Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.

Question 4 of 5

In the management process, the periodic checking of the results of action to make sure that it coincides with the goal of the institution is termed as:

Correct Answer: B

Rationale: The correct answer is B: Evaluating. Evaluating involves the periodic checking of results to ensure they align with the institution's goals. Planning (choice A) is about setting goals and determining the actions required to achieve them. Directing (choice C) involves overseeing and guiding the activities of individuals or teams to accomplish goals. Organizing (choice D) is about arranging resources and tasks to achieve objectives. In the context of the management process described, evaluating best fits the action of checking results against goals.

Question 5 of 5

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.

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