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 D

Explanation

D. Respiratory acidosis occurs when there is inadequate alveolar ventilation, leading to retention of carbon dioxide (hypercapnia) in the blood. The accumulation of carbon dioxide results in an increase in the partial pressure of carbon dioxide (PaCO2), leading to respiratory acidosis.

A. Hyperventilation refers to breathing at a rate and depth that exceeds the body's metabolic needs, leading to a decrease in the partial pressure of carbon dioxide (PaCO2) in the blood. Respiratory acidosis, however, is characterized by an increase in PaCO2 due to inadequate ventilation, not rapid elimination of carbon dioxide.

B. This choice refers to the hypoxic drive, which is a compensatory mechanism triggered by low oxygen levels in the blood. While hypoxemia (low oxygen levels) can stimulate the respiratory rate, it typically occurs in chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) rather than acute respiratory acidosis.

C. While the kidneys play a role in regulating acid-base balance through the excretion of hydrogen ions and reabsorption of bicarbonate ions, they do not directly eliminate carbon dioxide from the body.

A. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. D. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines.

Correct Answer is B

Explanation

B. Isolating the client is crucial to minimize exposure to individuals who are not wearing proper PPE and to reduce the risk of spreading the virus within the healthcare setting and among family members.

A. is important for informing family members about potential exposure and monitoring for symptoms, but it is not as immediate as isolating the client to prevent further transmission.

C. is also important for educating the client on preventive measures to reduce the spread of the virus, but isolating the client takes precedence in the immediate management of potential COVID-19 cases.

D. is important for public health surveillance and contact tracing efforts, but it is not as immediate as isolating the client and educating them about preventive measures.

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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 is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

Correct Answer is D

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

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