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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Rationale
The frequency and amount of urination indicates that the body in able to utilize glucose reducing glucosuria and osmotic diuresis.
The ability to tolerate oral intake also indicates an improvement in the client’s general health
Improvement in perception of pedal pulses indicates an improvement in the hydration status of the client.
A normal pulse rate and blood pressure is an indicator of optimal hydration status- an improvement from the severely dehydrated state.
The blood glucose levels is dropping indicating an improvement in the glycemic control
Correct Answer is A
Explanation
A. Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.
B. Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.
D. While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.
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