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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. High fever. – Incorrect. Fever can occur with infection but is not a hallmark sign of sickle cell crisis.
B. Constipation. – Incorrect. Constipation is not a defining symptom of sickle cell crisis.
C. Bradycardia. – Incorrect. Tachycardia, not bradycardia, is common due to pain and hypoxia.
D. Pain. – Correct Answer. Severe pain is the most common symptom of sickle cell crisis due to vaso-occlusion and ischemia.
Correct Answer is D
Explanation
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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