A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?
Apply oxygen by nasal cannula.
Administer an anticonvulsant medication.
Turn the client to a lateral position.
Check the client's oxygen saturation.
The Correct Answer is C
C. The priority during a seizure is to protect the patient from harm, particularly from aspiration if they vomit or have excessive saliva production. Turning the client to a lateral position helps maintain an open airway and prevents aspiration. This action should be taken immediately after lowering the client to the floor to ensure their safety.
A. Providing oxygen is important for a patient experiencing a seizure. However, it's not the first action to take. The priority is to ensure the patient's safety and protect them from injury during the seizure.
B. Administering anticonvulsant medication during an active seizure is not appropriate. Anticonvulsants are typically prescribed as maintenance therapy to prevent seizures or to manage seizure disorders in a controlled manner, not during an acute seizure episode.
D. Monitoring oxygen saturation is important but it's not the first action to take during an active seizure. Ensuring the patient's safety and protecting them from injury take precedence. Oxygen saturation can be assessed once the patient is in a safe position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The sweat chloride test is considered the most definitive diagnostic test for cystic fibrosis. In this test, sweat is collected from the skin and analyzed for chloride content. Elevated levels of chloride in the sweat are indicative of cystic fibrosis. This test is highly sensitive and specific for diagnosing the condition.
B. Stool fat content analysis can help assess pancreatic function and malabsorption, which are common manifestations of cystic fibrosis. However, it is not considered the most definitive test for diagnosing cystic fibrosis. Elevated stool fat content can be suggestive of cystic fibrosis but is not specific to the condition.
C. Sputum culture may be performed to identify respiratory pathogens and guide antibiotic therapy in individuals with cystic fibrosis, but it is not the most definitive test for diagnosing the condition. It helps identify infections and monitor lung health but does not confirm the diagnosis of cystic fibrosis.
D. Pulmonary function tests are used to assess lung function and airflow, which can be affected in individuals with cystic fibrosis. While these tests provide valuable information about lung health, they are not the most definitive test for diagnosing cystic fibrosis. They are used for monitoring disease progression and response to treatment rather than confirming the diagnosis.
Correct Answer is A
Explanation
A. Prompt initiation of appropriate antibiotics is essential to prevent the spread of infection, alleviate symptoms, and promote healing.
B. Surgical debridement of necrotic tissue is often necessary for treating acute osteomyelitis, especially if there is extensive tissue damage or the formation of abscesses. Surgical intervention aims to remove infected and dead tissue, reduce bacterial load, and promote wound healing.
C. Antipyretic therapy, such as acetaminophen or ibuprofen, may be administered to reduce fever and alleviate associated symptoms in clients with acute osteomyelitis. While fever management is important for comfort and overall well-being, it may not be the immediate priority unless the fever is high or causing significant distress.
D. Adequate nutrition and hydration support immune function, tissue repair, and overall recovery. However, while important for long-term management, optimizing nutrition and hydration may not be the immediate priority unless the client is severely malnourished or dehydrated.
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