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 B
Explanation
B. pH 7.46, PCO2 55 mm Hg, HCO3 36 mEq/L, PO2 95 mm Hg
The pH is high (alkalotic).
The HCO3 level is elevated, indicating metabolic alkalosis.
The PCO2 is high (respiratory acidotic picture due to secondary response). This option matches the criteria for metabolic alkalosis.
A. pH 7.30, PCO2 20 mm Hg, HCO3 22 mEq/L, PO2 85 mm Hg
The pH is low (acidic), not alkalotic.
The HCO3 level is within the normal range.
The PCO2 is low, which could indicate respiratory alkalosis. This option does not match the criteria for metabolic alkalosis.
C. pH 7.49, PCO2 45 mm Hg, HCO3 32 mEq/L, PO2 90 mm Hg The pH is high (alkalotic).
The HCO3 level is elevated, indicating metabolic alkalosis. The PCO2 is within the normal range.
This option does not meet the criteria for metabolic alkalosis D pH 7.29, PCO2 35 mm Hg, HCO3 25 mEq/L, PO2 99 mm Hg
The pH is low (acidic), not alkalotic. The HCO3 level is low, not elevated. The PCO2 is within the normal range.
This option does not match the criteria for metabolic alkalosis.
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.
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