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 C

Explanation

A. Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change. Incorrect, as the item is contaminated and should not be used.

B. Begin the dressing change by applying sterile gloves and removing the existing dressing. The old dressing should be removed with clean gloves before donning sterile gloves.

C. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray. Any contamination of the sterile field requires a complete restart to maintain sterility.

D. Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. Contaminates the sterile field; old dressings should be disposed of immediately.

A. Smoking B. Alcohol consumption C. Inflammatory bowel disease D. High-fat diet E. Colorectal polyps

Correct Answer is ["A","B","D"]

Explanation

A. Smoking – Smoking increases the risk of colorectal cancer and can be changed.

B. Alcohol consumption – Alcohol use increases cancer risk and is modifiable.

C. Inflammatory bowel disease – This is a non-modifiable risk factor.

D. High-fat diet – Dietary habits can be changed to lower the risk.

E. Colorectal polyps – Polyps are a non-modifiable risk factor.

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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

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Correct Answer is ["A","B","D"]

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