A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Check the patency of the client's airway.

Determine the poison that was ingested.

Position the client side-lying

Identify the amount of poison that was ingested.

Answer and Explanation

The Correct Answer is A

A. Checking the patency of the client's airway is the priority action because maintaining a clear airway is crucial during a seizure to ensure adequate oxygenation and prevent aspiration.
B. Determining the poison is important but not the immediate priority during a seizure.
C. Positioning the client side-lying is important to prevent aspiration, but the first action should be to ensure the airway is clear.
D. Identifying the amount of poison ingested is important for treatment but not the immediate priority during a seizure.

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Correct Answer is D

Explanation

A. Returning the excess medication to the secure cabinet is not appropriate as it can lead to contamination and safety issues.
B. Saving the excess medication for the next administration is not safe practice due to potential contamination.
C. Placing the excess medication in the sharps container is not the correct procedure for disposing of controlled substances.
D. Having a second nurse witness the disposal of the excess medication ensures proper documentation and accountability for controlled substances.

A. Remove the nasal cannula while the client eats. B. Attach a humidifier bottle to the base of the flow meter. C. Apply petroleum jelly to the nares as needed to soothe mucous membranes. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is B

Explanation

Rationale:

A. Removing the nasal cannula while the client eats can interrupt oxygen therapy.

B. Attaching a humidifier bottle to the base of the flow meter helps to humidify the oxygen, preventing dryness and irritation of the nasal passages, which is appropriate for oxygen flow rates above 4 L/min.

C. Applying petroleum jelly to the nares can pose a fire hazard due to its petroleum base.

D. Securing the oxygen tubing to the bed sheet is not necessary and does not ensure the proper administration of oxygen.

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A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Nursing Test Bank

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