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?

"You will need to take this medication with food from now on."

"You should avoid dangerous activities because of the side effects you are experiencing."

"The medication is usually prescribed for a short time, and the side effects may go away."

"You can use sugarless gum or candy to relieve some of those symptoms."

Answer and Explanation

The Correct Answer is B

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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Correct Answer is C

Explanation

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.

A. Glucose level at least 600 mg/dL B. Fruity, acetone smell to the breath C. Absence of ketones in the urine D. Polyuria and polydipsia E. Rapid, deep breathing.

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

Explanation

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

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

Explanation

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