a client with multiple sclerosis is admitted with an acute exacerbation what is the nurses priority action
Logo

Nursing Elites

HESI RN

HESI Exit Exam RN Capstone

1. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?

Correct answer: C

Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.

2. A client with a head injury reports severe nausea. What is the nurse's priority action?

Correct answer: D

Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.

3. Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?

Correct answer: A

Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.

4. A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.

5. A client with hypothyroidism is prescribed levothyroxine. What instruction should the nurse provide?

Correct answer: A

Rationale: The correct answer is A: 'Take the medication in the morning before eating.' Levothyroxine should be taken on an empty stomach in the morning for optimal absorption. Choice B is incorrect because while taking medication with water is generally recommended, levothyroxine specifically needs to be taken on an empty stomach. Choice C is incorrect as taking levothyroxine with food can interfere with its absorption. Choice D is incorrect as levothyroxine should be taken regularly as prescribed, not only when symptoms worsen.

Similar Questions

A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?
A client with deep vein thrombosis (DVT) is receiving heparin and reports tarry stools. What should the nurse do?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses