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 ["3.1"]
Explanation
1kg = 2.205lbs Weight in kgs= 9.979
Desired dose= 10mg/kg Dose= 99.79mg
Volume= desired dose/ available concentration per ml Volume= 99.79mg/ 32
Volume= 3.12mls
Therefore, the nurse should administer 3.1mls
Correct Answer is B
Explanation
B. The most serious complication associated with skeletal traction is osteomyelitis, an infection that involves the bone. This condition can occur when organisms gain access to the bone either systemically or through the openings created by the metal pins or wires used in the traction.
A. Increased blood pressure can occur for various reasons but it is not the most serious complication associated with skeletal traction.
C. A decrease in urine output could indicate systemic infection which is a late feature of osteomyelitis and therefore, not the earliest to monitor.
D. Changes in appetite can occur in response to pain or stress but they are not typically the most serious complication associated with skeletal traction.
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