A nurse is caring for a patient who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Place a pillow under the patient's head.

Loosen restrictive clothing.

Clear the area of hazards.

Position the patient in a side-lying position.

Answer and Explanation

The Correct Answer is D

A. Placing a pillow under the patient's head is inappropriate because it may obstruct the airway and does not prevent aspiration.

B. Loosening restrictive clothing can be helpful but is not the priority over airway protection.

C. Clearing the area of hazards is important to prevent injury, but airway protection takes precedence.

D. Positioning the patient in a side-lying position is the priority to maintain airway patency and reduce the risk of aspiration in case of vomiting.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Give the patient access to a video about diabetes. – Incorrect. Educational materials are helpful but should be provided after assessing the patient's current knowledge level.

B. Determine what the patient knows about managing diabetes. – Correct Answer. The first step in teaching is to assess the patient's baseline knowledge to tailor the education to their needs.

C. Establish short-term, realistic goals for the patient. – Incorrect. Goal-setting is important but should come after assessing the patient’s knowledge and readiness to learn.

D. Evaluate the effectiveness of the patient's admission teaching plan. – Incorrect. The nurse should first determine what new information needs to be taught before evaluating previous teaching.

A. Inserting an indwelling urinary catheter B. Putting a nasogastric (NG) tube in place C. Maintaining a patent airway D. Administering an enema daily

Correct Answer is C

Explanation

A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.

B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.

C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.

D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.

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A nurse is caring for a patient who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a teaching plan for a patient who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first?

Correct Answer is B

Explanation

Which nursing intervention takes highest priority for the nurse caring for an unconscious patient?

Correct Answer is C

Explanation

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