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 C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

A. Monitor the client's temperature once every 6 hr. B. Make sure the client's room has positive-pressure airflow. C. Wear an N95 respirator when providing direct client care. D. Make sure dietary plates and utensils are disposable.

Correct Answer is C

Explanation

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

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