A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Provide oxygen.

Turn the client onto his side.

Provide privacy.

Lower the client to the floor.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.

Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.

Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.

Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.

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Correct Answer is D

Explanation

Choice A reason: This is an incorrect action, because emptying the drainage container every 4 hr is not necessary and can interfere with the accurate measurement of the drainage volume. The drainage container should be emptied only when it is full or at the end of the shift.

Choice B reason: This is an incorrect action, because changing the client's insertion-site dressing each shift can increase the risk of infection and dislodgment of the chest tube. The insertion-site dressing should be changed only when it is soiled or loose.

Choice C reason: This is an incorrect action, because clamping the chest tube when the client is ambulating can cause a tension pneumothorax, which is a life-threatening complication of chest tube insertion. The chest tube should be clamped only when ordered by the provider or when changing the drainage system.

Choice D reason: This is the correct action, because placing the drainage unit below the client's chest level can facilitate the drainage of air and fluid from the pleural space by gravity. The drainage unit should be kept below the client's chest level at all times.

A. Kussmaul respirations B. Diaphoresis C. Decreased skin turgor D. Ketonuria

Correct Answer is B

Explanation

Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.

Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.

Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.

Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.

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A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Nursing Test Bank

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Explanation

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Correct Answer is B

Explanation

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