A 25-year-old patient with a history of epilepsy is brought to the emergency department after experiencing a generalized tonic-clonic seizure. Which of the following is the most appropriate initial action by the nurse?

Apply soft restraints to prevent injury during the seizure.

Administer intravenous lorazepam.

Obtain a detailed seizure history from the family.

Ensure the patient's airway is open and position them on their side.

Answer and Explanation

The Correct Answer is D

A.   Applying soft restraints during a seizure could increase the risk of injury and is not recommended.
B.   Administering lorazepam is often necessary in seizures, but the priority during a seizure is ensuring the airway is open and the patient is in a safe position.
C.   Obtaining a seizure history is important but should be done after managing the acute situation.
D.   The priority during a seizure is to ensure the patient's airway is open and to position them on their side to prevent aspiration and facilitate breathing.

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Correct Answer is B

Explanation

A. Decreased blood pressure is not typically associated with contrast-induced nephropathy. In fact, patients may present with normal or elevated blood pressure, especially in those with a history of chronic hypertension.
B. Metabolic acidosis is a common complication of acute kidney injury (AKI), including contrast-induced nephropathy. As kidney function declines, the kidneys' ability to excrete acids diminishes, leading to the accumulation of acids in the blood and resulting in metabolic acidosis.
C. Hypocalcemia is not a common feature of contrast-induced nephropathy. While AKI can cause disturbances in calcium and phosphate balance, hypocalcemia is not typically a predominant finding.
D. Increased urine specific gravity may not be a significant finding in contrast-induced nephropathy. This condition generally leads to impaired kidney function, which may present with urine output changes, but urine specific gravity can vary depending on the stage of AKI.

A. Increase the oxygen flow rate to 4 L/min to improve oxygenation. B. Switch the patient to a non-rebreather mask for better oxygenation. C. Continue to monitor the patient closely and reassess in 30 minutes. D. Reduce the oxygen flow rate to 1 L/min and notify the healthcare provider.

Correct Answer is D

Explanation

A. Increasing the oxygen flow rate could worsen respiratory depression in patients with COPD, as they rely on low oxygen levels to stimulate breathing.
B. Switching to a non-rebreather mask could further elevate the oxygen levels and may lead to hypoventilation or respiratory distress.
C. Monitoring the patient closely and reassessing in 30 minutes might be appropriate if the patient shows no immediate signs of respiratory distress, but the priority is to address the decreased respiratory rate.
D. Reducing the oxygen flow rate to 1 L/min and notifying the healthcare provider is the most appropriate action, as it may reduce the risk of respiratory depression caused by excessive oxygen.

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A 25-year-old patient with a history of epilepsy is brought to the emergency department after experiencing a generalized tonic-clonic seizure. Which of the following is the most appropriate initial action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 72-year-old patient with a history of chronic hypertension is diagnosed with acute kidney injury (AKI) secondary to contrast-induced nephropathy. Which clinical finding would most likely be present in this patient?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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