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. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.
B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.
C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.
D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.
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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