Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

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

A.

Determine neurological baseline prior to the fall.

B.

Determine client’s last dose of corticosteroids.

C.

Administer a PRN IV antiemetic as prescribed.

D.

Complete head to toe neurological assessment.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.

 

Choice B rationale

 

Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.

 

Choice C rationale

 

Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.

 

Choice D rationale

 

Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.

 


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is D

Explanation

Choice A rationale

Storing the medication at room temperature is appropriate for ipratropium inhalers. This ensures the medication remains effective and safe for use.

Choice B rationale

Attaching a spacer device to the inhaler is recommended for patients using ipratropium inhalers. A spacer helps deliver the medication more effectively to the lungs and reduces the risk of side effects.

Choice C rationale

Rinsing the mouth after each use of the inhaler is a good practice to prevent oral thrush and other side effects. It is a recommended step in the proper use of inhalers.

Choice D rationale

Priming the inhaler with 7 pumps is excessive. Typically, inhalers need to be primed with 2-4 pumps before first use or if they haven’t been used for a while. Over-priming can waste medication and indicate a need for additional teaching.

Correct Answer is D

Explanation

Choice A rationale

Laying down on each side with knees bent and breathing from the abdomen is not an effective technique for improving gas exchange in emphysema patients.

Choice B rationale

Increasing the breathing rate for a full 30 seconds can lead to hyperventilation and is not recommended for improving gas exchange.

Choice C rationale

Raising hands above the head to expand the diaphragm is not a recognized technique for improving gas exchange in emphysema patients.

Choice D rationale

Drawing air in through the nose and exhaling slowly through pursed lips is an effective technique for improving gas exchange in emphysema patients. This method helps to keep the airways open longer and improves the removal of trapped air.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.