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. Pernicious anemia is a condition related to vitamin B12 deficiency and does not typically cause blood-tinged urine.
B. Prostate enlargement (benign prostatic hyperplasia) can cause urinary symptoms like hesitancy and frequency but does not directly cause blood-tinged urine.
C. Dehydration can lead to concentrated urine and urinary tract irritation but does not typically cause blood-tinged urine.
D. Blood-tinged urine in a client with an indwelling urinary catheter is concerning for a bladder infection, especially if accompanied by other signs like fever or foul odor.

A. Take the client's temperature once per shift. B. Provide the client with fresh fruit to avoid constipation. C. Limit the number of health care workers entering the room. D. Insert an indwelling catheter to monitor sediment in the urine.

Correct Answer is C

Explanation

Rationale:
A. Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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