care plan and postoperative care

Which of the following are components of the "3V" rule applied when a patient is admitted from the recovery room?

• verificaiton, vital signs, vocalization

• validation, verbalization, vitality

• vital signs, ventialation, visualization

• verification, verbalization, visualization

How often should the vital signs of a patient after surgery be monitored within the first hour?

• Every 30 minutes

• Every 15 minutes

• Once every hour

• Every 5 minutes

What should the nurse do before transferring the patient to the bed?

• Start the patient's diet immediately

• Ask for another staff member's help to safely move the patient

• Ask for another staff member's help to safely move the patient

• Tell the patient to go to the bathroom by themselves

Which safety measure must be taken to prevent the patient from falling in the ward?

• Keeping the bed at the highest position.

• Leaving the side rails down so the patient can get out easily.

• Raising the side rails and keeping the call bell within the patient's reach.

• Asking the patient to walk alone as soon as they arrive.

According to the objective data for John Doe, which of the following clinical findings indicates that the patient is experiencing hypoxia?

• A heart rate of 102 bpm

• temperature of 38.5°C

• Oxygen saturation of 90% on room air

• Elevated WBC count in laboratory results

The nursing diagnosis "Ineffective Airway Clearance" is primarily supported by which patient symptom?

• Chest pain when breathing deeply

• Productive cough with yellowish sputum and crackles

• A blood pressure of 130/85 mmHg

• Reporting feelings of chills and fever

What is the primary medical rationale for positioning a pneumonia patient in "high-Fowler’s" (60–90°)?

• To reduce the patient's body temperature

• To help thin the mucus for easier expectoration

• To enhance lung expansion and improve oxygenation

• To prevent the recurrence of a bacterial infection

Which intervention is specifically designed to help the patient thin their mucus so it is easier to cough up?

• Administering prescribed antibiotics

• Providing adequate oral or IV hydration

• Monitoring vital signs every 4 hours

• Monitoring vital signs every 4 hours

Based on the "Planning" section, what is the expected short-term outcome for the patient's oxygen levels within 48 hours? (Answer the question according to the care plan)

• Oxygen saturation will stay at 90% without help

• Oxygen saturation will improve to 95% or higher with supplemental oxygen

• The patient will no longer need any oxygen therapy

• The respiratory rate will decrease to 10 breaths per minute

Look at the "Evaluation" section. Which statement proves that the intervention for "Activity Intolerance" was successful?

• The patient’s temperature decreased to 37°C

• Crackles are still heard in bilateral lower lung fields

• The patient can tolerate light activities with less fatigue and dyspnea

• The patient can tolerate light activities with less fatigue and dyspnea