A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Determine the client's last dose of corticosteroids.

Determine neurological baseline prior to the fall.

Administer a PRN IV antiemetic as prescribed.

Complete head-to-toe neurological assessment.

Answer and Explanation

The Correct Answer is D

A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.

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Correct Answer is D

Explanation

A. Use salt tablets after strenuous exercise is incorrect. Clients with hypernatremia should avoid excessive sodium intake, including salt tablets, as this can worsen the condition.

B. Drink plenty of water whenever thirsty is incorrect. Thirst is a late sign of dehydration, and clients with hypernatremia should be encouraged to drink water regularly, even before feeling thirsty, to maintain proper hydration and correct sodium imbalances.

C. Monitor daily urine output volume is incorrect. While monitoring fluid balance is important, urine output alone does not directly address sodium intake or management, making reviewing food labels for sodium content a more critical intervention.

D. Review food labels for sodium content is correct. Clients with hypernatremia should limit sodium intake by carefully reading food labels and avoiding processed, canned, and fast foods that are high in sodium.

Correct Answer is ["0.5"]

Explanation

Volume (mL) = Desired dose (mg) / Concentration (mg/mL)

First, we need to calculate the concentration of the reconstituted solution:

Concentration (mg/mL) = Total amount of drug (mg) / Total volume (mL)

Total amount of drug = 0.3 mg
Total volume = 1.2 mL

Concentration (mg/mL) = 0.3 mg / 1.2 mL = 0.25 mg/mL

Now, we can calculate the volume to administer:

Volume (mL) = 0.125 mg / 0.25 mg/mL = 0.5 mL

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A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Correct Answer is D

Explanation

Correct Answer is ["0.5"]

Explanation

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