A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Loosen the client's clothing.

Help the client lie on the floor.

Turn the client onto their side.

Move items in the room away from the client.

Answer and Explanation

The Correct Answer is B

A. Loosen the client's clothing:
While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.
B. Help the client lie on the floor:
This is the correct answer. When a client is having a seizure, the priority is to ensure their safety. Lying the client on the floor helps prevent injury during the seizure, reducing the risk of falling from a chair or bed. Placing the client in a lateral (side) position can also help maintain an open airway.
C. Turn the client onto their side:
This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.
D. Move items in the room away from the client:
While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.

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Correct Answer is ["A","B","C","F"]

Explanation

A.Swollen tongue: Swelling of the tongue can indicate an allergic reaction, which could progress to a severe condition known as anaphylaxis. Immediate intervention is necessary.

B. Heart rate: While the heart rate is not directly mentioned in the notes, an increase in heart rate could be a physiological response to an allergic reaction or anaphylaxis. Monitoring heart rate is crucial in assessing the severity of the reaction.

C. Bilateral breath sounds with scattered wheezing upon auscultation: Wheezing indicates a potential respiratory issue, and when associated with itching, urticaria, and swelling, it suggests an allergic reaction or anaphylaxis. Prompt intervention is needed.

D. Blood pressure: Although blood pressure is important to monitor, it is not directly mentioned in the nurses' notes. However, if anaphylaxis or a severe allergic reaction is suspected, blood pressure can be affected, and it should be monitored.

E. Temperature: Fever is not mentioned in the notes, and the information provided suggests an immediate allergic reaction rather than an infectious process. Monitoring temperature is generally important but may not be a priority in this specific context.

F.Urticaria (hives): Hives are a sign of an allergic reaction and, when accompanied by other symptoms like swelling, require immediate attention.

A. Use a quick-release knot to secure the ties. B. Cut the old ties after the new ties are secured. C. Allow space for three fingers under the ties when securing. D. Extend the client's neck while securing the ties

Correct Answer is B

Explanation

Correct answer: B

A. Use a quick-release knot to secure the ties:

This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.

B. Cut the old ties after the new ties are secured:

This is the safest approach. It ensures the tracheostomy tube remains secure throughout the change.

C. Allow space for three fingers under the ties when securing:

Two fingers is the recommended space to allow for breathing comfort and prevent the tube from being too loose..

D. Extend the client's neck while securing the ties:

This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.

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A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","F"]

Explanation

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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