A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Place the client on their side with their head forward.

Administer an anticonvulsant medication.

Time the length of the client's seizure.

Loosen the client's gown and allow them to move freely.

Answer and Explanation

The Correct Answer is A

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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Correct Answer is B

Explanation

A. Initiate a new IV line below the original insertion site. – If phlebitis or infection is present, a new IV should be placed in another limb or at a site above the previous insertion, not below.

B. Discontinue the infusion. – The first step in treating suspected phlebitis or IV infiltration is stopping the infusion to prevent further tissue damage.

C. Raise the head of the bed. – Elevating the head of the bed is not relevant in managing IV site complications.

D. Obtain a culture from the area of the insertion site. – Cultures are not necessary unless infection is suspected and prescribed by a provider.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

i. Clean the puncture site with antiseptic and allow it to dry helps reduce the risk of infection and ensures an accurate reading by preventing contamination.

ii. Wipe away the first drop of blood before collecting the sample is the best next step because the first drop may contain tissue fluid, which can affect glucose accuracy.

Incorrect answers:

Warming the client's hand before performing the fingerstick improves blood flow, making it easier to obtain an adequate sample, especially in clients with diabetes who may have impaired circulation.

Massage the finger gently from the base toward the tip before puncturing promotes blood flow but should be done carefully to avoid excess squeezing, which can lead to inaccurate results.

Ensure the client's hand is below heart level when obtaining the sample encourages blood flow, making collection easier.

Apply firm pressure to the site after obtaining the sample prevents excessive bleeding and helps close the puncture site.

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A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the list of options. When obtaining a capillary blood sample for glucose testing, the nurse should dropdown, and then dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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