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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. According to the usage guidelines for ipratropium inhalers, priming the inhaler typically requires only two sprays into the air, away from the face, before the first use to ensure proper medication dosage.
B. Rinsing the mouth after each use is a recommended practice to prevent irritation and infection.
C. Storing the medication at room temperature is correct, as extreme temperatures can affect the medication's efficacy.
D. Attaching a spacer device to the inhaler is also a recommended practice to improve medication delivery and reduce the risk of side effects.
Correct Answer is B
Explanation
B. Obstruction of bile flow leads to accumulation of bilirubin, a pigment produced by the breakdown of red blood cells, in the bloodstream and causes jaundice (yellowing of the sclera). Yellow sclera is a concerning sign that should be reported promptly to the healthcare provider as it indicates potential bile duct obstruction and impaired liver function
A. Amber urine refers to urine that is dark yellow, often indicating concentrated urine due to dehydration or certain medications. While amber urine may be noted in various conditions, it is not specifically indicative of a complication related to cholelithiasis.
C. While flatulence may be uncomfortable for the client, it is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
D. belching may be uncomfortable for the client but is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today