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 C

Explanation

Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.

Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.

Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.

Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.

A. Maternal-fetal B. Fecal-oral contamination C. Genital sexual contact D. Blood to blood

Correct Answer is B

Explanation

Choice A reason: This is an incorrect route, because maternal-fetal transmission of hepatitis A is very rare and occurs only if the mother has acute hepatitis A during the third trimester of pregnancy.

Choice B reason: This is the correct route, because fecal-oral contamination of hepatitis A is the most common mode of transmission. Hepatitis A is a viral infection that affects the liver and is spread through ingestion of contaminated food or water, or contact with infected feces.

Choice C reason: This is an incorrect route, because genital sexual contact of hepatitis A is uncommon and occurs only if there is oral-anal contact with an infected person.

Choice D reason: This is an incorrect route, because blood to blood transmission of hepatitis A is also uncommon and occurs only if there is exposure to infected blood or blood products, such as through needle sharing or transfusion.

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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?

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