A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Hold the client's arms and legs from moving.
Place the client back in bed.
Place the client on his side.
Insert a tongue blade in the client's mouth.
The Correct Answer is C
Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the floor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.
Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
feet or toes that occurs at night and is not relieved by rest.
Correct Answer is ["75"]
Explanation
To calculate the infusion rate, divide the volume of fluid by the time in hours. In this case, 1800 mL / 24 hr = 75 mL/hr.
Round the answer to the nearest whole number and use a leading zero if it applies.
Do not use a trailing zero because it could be misread as a decimal point. Therefore, the nurse should set the IV pump to deliver 75 mL/hr.
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