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. External cardiac pacemaker: If atropine is ineffective in treating symptomatic sinus bradycardia, the next step is the use of an external cardiac pacemaker which helps regulate the heart rate by providing electrical stimulation to the heart, addressing the bradycardia and improving circulation.

B. Amiodarone: Amiodarone is an antiarrhythmic drug used for treating ventricular arrhythmias or atrial fibrillation, not for bradycardia. The priority for bradycardia management is pacing rather than antiarrhythmic medications.

C. Magnesium: Magnesium is primarily used for treating specific arrhythmias like torsades de pointes, particularly in the presence of hypomagnesemia. It is not indicated for symptomatic sinus bradycardia, especially after atropine fails.

D. Cardioversion: Cardioversion is used to treat arrhythmias such as atrial fibrillation or supraventricular tachycardia, not bradycardia. Since the issue is a slow heart rate, not an abnormal rhythm needing electrical shock, cardioversion is not appropriate in this case.

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Correct Answer is A

Explanation

A. Respiratory acidosis: Respiratory acidosis occurs when CO2 accumulates due to impaired ventilation, leading to a decrease in pH. The elevated PaCO2 (48 mm Hg) and low pH (7.32) confirm respiratory acidosis. Normal HCO3 (23 mEq/L) suggests no renal compensation at this point.

B. Respiratory alkalosis: Respiratory alkalosis is marked by a decrease in PaCO2, which is not seen here as the PaCO2 is elevated. A low pH further contradicts alkalosis, as it should be elevated. Therefore, respiratory alkalosis is not supported by these ABG values.

C. Metabolic acidosis: Metabolic acidosis shows a decrease in HCO3, which is normal in this case (23 mEq/L). Additionally, the elevated PaCO2 points to a respiratory origin of the acidosis, not a metabolic cause.

D. Metabolic alkalosis: Metabolic alkalosis involves elevated HCO3 and a higher pH, which is not observed here. The bicarbonate level is normal, and the pH is low, ruling out metabolic alkalosis. The primary issue in this case is respiratory acidosis, not metabolic.

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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 nurse is caring for a client who has symptomatic sinus bradycardia. The Atropine was given but was not successful. Which one of the following is the next intervention?

Correct Answer is A

Explanation

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid-base balances?

Correct Answer is A

Explanation

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