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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Epinephrine is a medication commonly used to treat severe allergic reactions, also known as anaphylaxis. One of the hallmark signs of anaphylaxis is difficulty breathing or shortness of breath. Epinephrine works by constricting blood vessels, relaxing smooth muscles in the airways, and reducing swelling, which can help relieve the symptoms of respiratory distress. Epinephrine is not typically used to treat nausea, hyperglycemia, or hand tremors.
Nausea can be caused by various factors and is usually managed with antiemetic medications. Hyperglycemia, which refers to high blood sugar levels, is typically managed with appropriate diabetes management, including insulin or other glucose-lowering medications. Hand tremors can have different underlying causes, and their treatment depends on the specific etiology.
Correct Answer is C
Explanation
Explanation:
When a charge nurse observes the smell of alcohol on a nurse's breath, it raises concerns about their ability to provide safe and competent care to clients. Patient safety is of utmost importance, and the charge nurse must take immediate action to address the situation.
Removing the nurse from the client care area ensures that the nurse is not involved in direct patient care while their ability to provide safe care is in question. This step helps mitigate potential risks to patient safety.
B and D- After removing the nurse from the client care area, further actions can be taken, such as documenting the objective findings about the situation and informing the supervisor. However, the immediate priority is to ensure patient safety by removing the nurse from the care area.
A- Assigning clients to the remaining staff can be done once the situation has been addressed and a suitable replacement for the nurse has been arranged.
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