A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?
Apply restraints if the client is agitated.
Ambulate the client.
Position the client on their side.
Raise all of the side rails on the client's bed.
The Correct Answer is C
A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
ML
The formula to calculate the IV flow rate is:
mL/hr =
(Desireddose(units/hr)×Totalvolume(mL))/ Available dose
Substituting the given values:
(1,000×250)/25000
= 250,000/25,000
= 10ml/hr
Correct Answer is B
Explanation
A. Schedule the client for an MRI after the procedure. This is incorrect because an MRI is not required following a thoracentesis. Instead, a chest X-ray may be ordered to assess for complications such as a pneumothorax.
B. Place the client leaning forward over the overbed table. This is correct because this position allows for optimal lung expansion and easier access to the pleural space for fluid removal.
C. Encourage the client to take deep breaths during the procedure. This is incorrect because the client should remain still and avoid deep breathing or coughing to prevent lung injury.
D. Ensure the client has been NPO for 6 hr. This is incorrect because NPO status is not required for a thoracentesis, as it is not a gastrointestinal or sedation-based procedure.
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