A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure.

Which of the following actions should the nurse take?

Lower the side rails of the bed when the seizure begins.

Measure the duration of the seizure.

Restrain the client's arms and legs to prevent injury.

Insert an oral airway into the client's mouth.

Lower the side rails of the bed when the seizure begins.

Measure the duration of the seizure.

Restrain the client's arms and legs to prevent injury.

Insert an oral airway into the client's mouth.

Answer and Explanation

The Correct Answer is B

Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them.

Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention.

Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.

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Free Nursing Study Resources

Correct Answer is D

Explanation

D, Wash hands with soap and water for 20 seconds

Hand hygiene is a critical practice in preventing the transmission of infections in healthcare settings. Here's why the other options are incorrect:

Wearing sterile gloves when in contact with body fluids in (option A) is incorrect because it is important for preventing the transmission of pathogens, but it is not directly related to hand hygiene. Hand hygiene refers to the cleaning of hands to remove pathogens, and sterile gloves provide a barrier to protect the healthcare worker and the patient.

B. Using an alcohol-based cleanser when hands are visibly soiled in (option B) is not recommended. Alcohol-based cleansers are effective in killing many types of germs, but they are not as effective in removing visible dirt, blood, or body fluids. In such cases, it is important to wash hands with soap and water to thoroughly clean them.

Artificial nails should not be worn when performing direct client care in (option C). They can harbor and transmit pathogens and make it more difficult to effectively clean hands. The Centres for Disease Control and Prevention (CDC) recommends that healthcare workers maintain short, clean, and natural nails without the use of artificial nails or nail extensions.

A. Remove the tape by pulling from the center of the dressing B. Wear sterile gloves to remove the dressing C. Clean the wound from the center to the outer edges D. Moisten the dressing before removal

Correct Answer is C

Explanation

When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.

The other options listed are not recommended for this specific procedure:

When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.

While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.

In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?