A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Insert a padded tongue blade into the client's mouth.

Place a pillow under the client's head

Gently restrain the client's extremities.

Apply a face mask for oxygen administration

Answer and Explanation

The Correct Answer is B

A. Insert a padded tongue blade into the client's mouth: Inserting a tongue blade can cause harm, such as damaging the client's teeth or mouth or causing them to bite down on the blade, leading to injury. It is not recommended during a seizure.

B. Place a pillow under the client's head: Placing a pillow under the client’s head helps protect it from injury during the clonic phase of a seizure. This is the most appropriate and safest action to prevent head trauma while the client is experiencing a seizure.

C. Gently restrain the client's extremities: Restraint during a seizure can lead to injury and should be avoided. The priority is to allow the seizure to occur without interference, ensuring the client’s safety by preventing injury from the environment.

D. Apply a face mask for oxygen administration: Oxygen may be indicated if the client shows signs of respiratory distress, but applying a face mask immediately is not the priority. Ensuring safety during the seizure (e.g., protecting the head) is more important in the initial response.

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Correct Answer is A

Explanation

A. Start cardiopulmonary resuscitation (CPR): The client is apneic with no palpable pulses, indicating cardiac arrest. The immediate priority is to begin CPR to provide chest compressions and ventilation, which is essential for maintaining circulation and oxygenation.

B. Provide supplemental O2 via non-rebreather mask: While oxygen is crucial, the primary concern is restoring circulation and ensuring oxygenation through CPR. Oxygen administration alone won't address the lack of circulation, CPR should be started first.

C. Give atropine per agency dysrhythmia protocol: Atropine is typically used for bradycardia, not sinus tachycardia. The client's apneic state and lack of pulses indicate a more severe issue, such as cardiac arrest, which requires immediate CPR, not atropine.

D. Perform synchronized cardioversion: Synchronized cardioversion is used for specific arrhythmias such as atrial fibrillation or supraventricular tachycardia with a pulse. Since the client has no pulse, defibrillation (if indicated) or CPR should be initiated first, not synchronized cardioversion.

A. 8750mL B. 8000mL C. 8562mL D. 8502 mL

Correct Answer is C

Explanation

To calculate the total intravenous fluids infused in 24 hours for a burn client, use the Parkland formula.

Calculate Fluid Resuscitation Volume (Parkland Formula)

Convert client's weight from pounds (lb) to kilograms (kg).

Client weight = 147.4 lb / 2.2 lb/kg

= 67 kg.

Calculate the total fluid volume needed for the first 24 hours using the Parkland formula.

Parkland Formula = 4 mL × client weight (kg) × % TBSA burned

Total fluid volume (24 hrs) = 4 mL × 67 kg × 31.5%

= 8442 mL.

Calculate Insulin Infusion Volume in 24 hours

Concentration of the insulin solution = 100 units / 100 mL

= 1 unit/mL.

Calculate the volume of insulin solution infused per hour.

Infusion rate = 5 units/hr

Volume infused per hour (mL/hr) = Desired units/hr / Concentration (units/mL)

= 5 units/hr / 1 unit/mL

= 5 mL/hr.

Calculate the total volume of insulin solution infused in 24 hours.

Total insulin volume (24 hrs) = Volume infused per hour (mL/hr) × 24 hours

= 5 mL/hr × 24 hours

= 120 mL.

Calculate Total Intravenous Fluids Infused in 24 hours

Total IV fluids = Total fluid resuscitation volume + Total insulin volume

= 8442 mL + 120 mL Total IV fluids

= 8562 mL.

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A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client whose heart monitor shows sinus tachycardia, is apneic and has no palpable pulses. What action should the nurse ta next?

Correct Answer is A

Explanation

Calculate the total intravenous fluids infused in 24 hrs for a 147.4-lb client with a 31.5% TBSA burn and receiving insulin 5 units/hr. The concentration of insulin is 100 units in 100 mL normal saline.

Correct Answer is C

Explanation

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