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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.
"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.
"My baby will receive three doses of the meningococcal immunization before kindergarten." This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for the specific recommendations regarding the meningococcal immunization.
"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.
Correct Answer is D
Explanation
Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.
Conducting change-of-shift report near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct report in a designated area away from patient rooms to minimize disruptions.
Overhead lights should be avoided during nighttime or sleep hours as they are bright and can disrupt a client's sleep. Instead, nurses should use a low-intensity light or a flashlight to check IV lines or attend to other needs. This helps minimize disruptions to the client's rest.
Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today