Ati Nursingati Pn Comprehensive Exit Exam

1. The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a. Perform hand hygiene. b. Explain use of the mouthpiece. c. Instruct the patient to inhale slowly. d. Place in the reverse Trendelenburg position. ANS: A Performing hand hygiene reduces microorganisms and should be performed first. Placing the patient in the correct position such as high Fowler’s for the typical postoperative patient or reverse Trendelenburg for the bariatric patient would be the next step in the process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario. 2. The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP? a. Teach postoperative exercises. b. Do nothing associated with postoperative exercises. c. Document in the medical record when exercises are completed. d. Inform the nurse if the patient is unwilling to perform exercises. ANS: D The nurse can delegate to the NAP to encourage patients to practice postoperative exercises regularly after instruction and to inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate. 3. The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? “Start with clear liquids, soup, and crackers. Advance to a normal diet a. as tolerated.” “Stay with ice chips for several hours. After that, you can have b. whatever you want.” “Stay on clear liquids for 24 hours. Then you can progress to a normal c. diet.” “Start with clear liquids for 2 hours and then full liquids for 2 hours. d. Then progress to a normal diet.” ANS: A Patients usually receive a normal diet the first evening after surgery unless they have undergone surgery on GI structures. Implement diet intake while judging the patient’s response. For example, provide clear liquids such as water, apple juice, broth, or tea after nausea subsides. If the patient tolerates liquids without nausea, advance the diet as ordered. There is no need to stay on ice chips for several hours or clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient’s needs.