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 A

Explanation

A. A corneal abrasion is a condition that may be exacerbated by the use of ketorolac due to its potential to delay healing and increase bleeding risks. Therefore, it is essential to ensure that a patient does not have a corneal abrasion before administering ophthalmic ketorolac.

B. Radiation exposure is not directly relevant to the administration of ophthalmic ketorolac.

C. The presence of a foreign body is not directly related to ketorolac use

D. The presence of a chemical burn is not related with ketorolac use in a client.

A. Secure tracheostomy ties by making knots close to the tube. B. Leave the old ties in place until the new ones are secure. C. Remove ties to secure a disposable, soft foam collar with self-adhesive fastening. D. Place knots of the ties laterally to prevent irritation and pressure.

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.

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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 receives a prescription for ophthalmic ketorolac, Prior to administering the medication, the nurse should review the medical record for which condition?

Correct Answer is A

Explanation

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

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