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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
Correct Answer is C
Explanation
A. Cyclobenzaprine is not indicated for relieving nausea.
B. Cyclobenzaprine is a muscle relaxant, not an antibiotic.
C. Cyclobenzaprine is a muscle relaxant used to relieve muscle spasms, which can occur with fractures.
D. Cyclobenzaprine does not have properties to reduce itching.
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