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

Determine client's last dose of corticosteroids.

Administer a PRN IV antiemetic as prescribed.

Determine neurological baseline prior to the fall.

Complete head-to-toe neurological assessment.

Answer and Explanation

The Correct Answer is D

D. The priority nursing intervention should be to assess and stabilize the patient's immediate medical needs. The confusion and vomiting could be indicative of increased intracranial pressure or another acute condition requiring immediate attention. Therefore, the most appropriate first action would be to complete a head-to-toe neurological assessment.

A. Determining the last dose of corticosteroids may not address the immediate concerns of confusion and projectile vomiting.

B. Administering an antiemetic is not the priority action as the vomiting is likely due to head trauma with subsequent raised ICP.

C. Understanding the baseline neurological status is essential for subsequent assessment and management but it may not address the immediate concerns of confusion and vomiting.

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Correct Answer is B

Explanation

B. This ensures that the tracheostomy tube remains stable and reduces the risk of the tube becoming dislodged during the process.
A. Tying knots close to the tracheostomy tube can increase the risk of pressure ulceration and irritation to the skin around the stoma.
C. A disposable, soft foam collar with self-adhesive fastening may be used for additional support and comfort, but it does not replace the need for securing the tracheostomy ties.
D. Placing knots laterally may not provide adequate support and can increase the risk of accidental displacement of the tracheostomy tube.

A. Auscultate the client's bowel sounds and measure the abdominal girth. B. Confirm that the client is taking the medication one hour after meals. C. Notify the healthcare provider that the client may need a change in dosage. D. Advise the client that healing typically takes several weeks to occur.

Correct Answer is D

Explanation

D. Since the client has reported only minimal reduction in symptoms after taking lansoprazole (a proton pump inhibitor used to treat GERD) for one full week, it suggests that the current dosage may not be sufficient for adequate symptom relief. Therefore, the nurse should notify the healthcare provider.

A. Auscultating the client's bowel sounds and measure the abdominal girth. This action is not directly related to the client's reported lack of symptom improvement with lansoprazole.

B. Lansoprazole is typically taken before meals to maximize its effectiveness in reducing gastric acid production.

C.While it is true that healing of erosive esophagitis may take several weeks with treatment, the client's report of minimal symptom reduction suggests that further evaluation and potentially a change in treatment approach are warranted.

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An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On 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

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the lies of the tracheostomy tube, which action is most important for the nurse to take?

Correct Answer is B

Explanation

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Correct Answer is D

Explanation

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

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