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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Correct Answer is C

Explanation

A. Clarify the prescription because the insulin should not be administered at this time. – Incorrect. Aspart insulin is rapid-acting and should be given with meals to prevent post-meal hyperglycemia.

B. Hold breakfast for one hour after the insulin administration. – Incorrect. Rapid-acting insulin peaks quickly (within 30-90 minutes), so delaying food increases the risk of hypoglycemia.

C. Administer insulin when breakfast arrives. – Correct Answer. Aspart insulin should be given right before or with food to match glucose absorption and prevent hypoglycemia.

D. Check the blood glucose immediately after breakfast. – Incorrect. Blood glucose should be checked before insulin administration to ensure appropriate dosing.

A. Regular and Humulin N B. Regular and Novolin N C. Lantus and Humulin N D. Humulin R and Novolin N

Correct Answer is C

Explanation

A. Incorrect. Regular insulin (short-acting) and Humulin N (intermediate-acting) can be mixed.

B. Incorrect. Regular insulin and Novolin N are compatible.

C. Correct. Lantus (glargine) is a long-acting insulin that should never be mixed with other insulins.

D. Incorrect. Humulin R (short-acting) and Novolin N (intermediate-acting) can be mixed.

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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?

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