A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client on their side.

Perform a neurologic check.

Obtain the client's vital signs.

Notify the rapid response team.

Answer and Explanation

The Correct Answer is A

A.   Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B.   While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C.   While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D.   Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.

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Correct Answer is B

Explanation

Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.

Telmisartan has no effect on respiratory rate, urine output or blood glucose.

A. Lower the head of the bed to semi-Fowler's. B. Change infusion to lactated Ringer's and maintain rate. C. Slow infusion rate and contact the provider. D. Administer prescribed corticosteroids.

Correct Answer is C

Explanation

A. This position may help alleviate dyspnea by promoting better lung expansion. However, it does not address the underlying issue of fluid overload or the need for urgent action. While helpful for comfort, this action alone is insufficient.
B. Switching the IV fluid to lactated Ringer's solution does not address the issue of fluid overload and is likely to worsen the situation.
C. Slowing the infusion can help mitigate further fluid overload, and contacting the provider is crucial for further evaluation and intervention. This option prioritizes the client’s safety and addresses the symptoms being experienced.
D. Corticosteroids are not typically used to address dyspnea and hypertension associated with IV fluid administration.

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A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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