Question 92
A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is:

Administering an antiemetic

Applying sequential compression devices

Assessing vital signs

Hanging the Lactated Ringers solution

Answer and Explanation

The Correct Answer is C

Choice A reason:
Administering an antiemetic is an important intervention in the PACU, especially if the patient is experiencing nausea or has a history of postoperative nausea and vomiting (PONV). However, it is not the first priority. Antiemetics work by blocking the neurotransmitters that trigger the vomiting reflex. Medications such as ondansetron or promethazine may be used.

Choice B reason:
Applying sequential compression devices is a preventive measure against deep vein thrombosis (DVT), which is a risk due to immobility after surgery. These devices help improve venous return from the lower limbs by applying intermittent pressure. While important, this intervention follows after the assessment of vital signs.

Choice C reason:
Assessing vital signs is the first and foremost priority when a patient is transferred to the PACU. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide immediate information about the patient's hemodynamic status and can indicate the need for urgent interventions. Any evidence of respiratory or circulatory compromise requires immediate attention.

Choice D reason:
Hanging the Lactated Ringers solution is part of managing the patient's fluid status postoperatively. Lactated Ringers is an isotonic solution that helps to replace lost fluids and maintain electrolyte balance. While important for patient care, it is not the initial priority upon arrival in the PACU.

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Correct Answer is ["B","D"]

Explanation

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

A. "You will need to take this medication with food from now on." B. "You should avoid dangerous activities because of the side effects you are experiencing." C. "The medication is usually prescribed for a short time, and the side effects may go away." D. "You can use sugarless gum or candy to relieve some of those symptoms."

Correct Answer is B

Explanation

Choice A Reason
Taking alprazolam with food may help with some gastrointestinal side effects but does not address the client's concerns about dizziness and light-headedness. While it is a practical suggestion, it is not the priority response when the client is experiencing symptoms that could affect their safety¹.

Choice B Reason
The priority for the nurse is to ensure the client's safety. Dizziness and light-headedness can increase the risk of falls or accidents, especially when performing tasks that require alertness, such as driving or operating machinery. Therefore, advising the client to avoid dangerous activities is the most immediate and appropriate response¹.

Choice C Reason
While it is true that alprazolam is often prescribed for short-term use and some side effects may diminish over time, this does not provide the client with a solution to their current symptoms. The nurse should address the client's immediate concerns and ensure their safety before discussing the duration of medication use¹.

Choice D Reason
Using sugarless gum or candy can help with dry mouth, which is a common side effect of alprazolam. However, this advice does not address the more serious side effects of dizziness and light-headedness that the client is experiencing. Therefore, it is not the priority response but can be included as additional advice¹.

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Question 92 A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Correct Answer is ["B","D"]

Explanation

Two months after beginning drug therapy with alprazolam, a client states, "I feel much better, but I can't believe how dizzy and light-headed I get, and sometimes my mouth feels dry." Which would be the priority response by the nurse?

Correct Answer is B

Explanation

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A 7-year-old child without any other diagnosed problems engages in jaw clenching and rocking behaviors. Which condition should the nurse anticipate?

A nurse is caring for a client diagnosed with left lower lobe pneumonia who experiences pain when coughing. Which intervention should the nurse include in the plan of care?

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A nurse formulates the problem of ineffective airway clearance for a client who has pneumonia. Which assessment data best supports this problem?

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply)

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Question 92
A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is: