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 A

Explanation

Choice a reason:
Including yogurt in the diet can be beneficial for a client experiencing diarrhea related to antibiotic therapy. Yogurt contains probiotics, which are live microorganisms that can provide health benefits when consumed. These probiotics can help restore the balance of good bacteria in the gut that antibiotics may have disrupted, potentially reducing the duration and severity of diarrhea. However, it's important to choose yogurts that contain active probiotics and to be aware that some individuals may not tolerate dairy well during a bout of diarrhea.

Choice b reason:
Administering famotidine 20 mg daily may help with symptoms of gastritis or peptic ulcers but is not directly related to treating antibiotic-associated diarrhea. Famotidine is a histamine-2 blocker used to reduce stomach acid and is not typically used as a treatment for diarrhea. It should be noted that if a patient is experiencing severe diarrhea, the underlying cause should be addressed rather than just managing symptoms.

Choice c reason:
Testing stool for occult blood is generally not a standard intervention for antibiotic-related diarrhea unless there is a suspicion of gastrointestinal bleeding or an infection like C. difficile, which can cause more severe colitis. Occult blood tests are more commonly used for screening for colorectal cancer or diagnosing conditions that cause gastrointestinal bleeding.

Choice d reason:
Arranging for IV administration of the antibiotic instead of the oral route may be considered if the client has severe diarrhea that prevents the absorption of oral medications or if the client is unable to tolerate oral intake[^10^]¹¹¹²¹³¹⁴. However, many antibiotics have excellent oral bioavailability, and switching from IV to oral antibiotics when appropriate can be just as effective and is often preferred due to convenience and lower risk of complications.

A. Weekly aerobic exercise at a gym B. Vitamin D deficiency C. Weight of <60 kg D. Trauma

Correct Answer is B

Explanation

Choice A Reason:
Weekly aerobic exercise at a gym is generally beneficial for joint health and is not a predisposing factor for osteoarthritis. Regular physical activity helps maintain joint flexibility, muscle strength, and overall health, which can actually help prevent the development of osteoarthritis.

Choice B Reason:
Vitamin D deficiency has been associated with an increased risk of osteoarthritis. Vitamin D is essential for bone health, and a deficiency can lead to changes in bone structure and strength, potentially contributing to the development and progression of osteoarthritis.

Choice C Reason:
A weight of less than 60 kg does not typically predispose an individual to osteoarthritis. In fact, maintaining a healthy weight can reduce the risk of developing osteoarthritis, as excess body weight can increase the stress on joints.

Choice D Reason:
Trauma can lead to post-traumatic osteoarthritis, which is a form of osteoarthritis that develops after an injury to a joint. Traumatic injuries can damage the cartilage and bone, leading to degenerative changes and osteoarthritis.

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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

The nurse would include which teaching or intervention in the care plan of a client experiencing diarrhea related to antibiotic therapy?

Correct Answer is A

Explanation

A 40-year-old client reports chronic lower back pain and stiffness. X-rays of the lumbar spine confirm the diagnosis of moderate to severe osteoarthritis. The nurse identifies which predisposing factor may have led to these degenerative changes?

Correct Answer is B

Explanation

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