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 A
Explanation
Rationale for A:
A small hematoma at the catheter insertion site is common after cardiac catheterization due to the puncture of blood vessels. The nurse should inform the client that this may occur but reassure them that it typically resolves on its own.
Rationale for B:
The dressing usually remains intact for 24 to 48 hours post-procedure to prevent infection and promote healing. The client should be instructed to keep the dressing clean and dry until the healthcare provider gives specific instructions.
Rationale for C: Clients are usually advised to avoid strenuous activities and exercise for several days after the procedure, not to resume regular exercise the next day.
Rationale for D: Pain medication may be necessary to manage discomfort post-procedure, and the nurse should encourage the client to take pain relief as needed.
Correct Answer is A
Explanation
a.This is appropriate as regular, moderate exercise can help improve cardiovascular health and functional capacity in clients with heart failure. It is essential to discuss appropriate types and levels of exercise based on the individual’s condition.
b.This is incorrect because clients should be instructed to notify the provider if they gain 1 kg (2.2 lbs) in one day or 2 kg (4.4 lbs) in one week. A weight gain of 0.5 kg is not typically a threshold for concern.
c. Take diuretics early in the morning and before bedtime is wrong because it may disrupt the client's sleep patern and cause nocturia. The nurse should advise the client to take diuretics early in the morning and avoid taking them in the evening or at night, unless prescribed otherwise.
d. Take naproxen for generalized discomfort is wrong because naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen heart failure by causing sodium and water retention, increasing blood pressure, and reducing the effectiveness of diuretics and other heart failure medications. The nurse should advise the client to avoid NSAIDs and use acetaminophen or other alternatives for pain relief, as prescribed by the provider.
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