A nurse is in a client’s room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Check the client’s motor strength.
Turn the client’s head to the side.
Document the time the seizure began.
Loosen the clothing around the client’s waist.
The Correct Answer is B
A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.
B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.
C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.
D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Applying petroleum jelly to the client’s lips after oral care can help prevent dryness and cracking, but it is not the primary action to ensure safety during oral care.
B: Turning the client on his side before starting oral care is the correct action. This position helps prevent aspiration of fluids and secretions during the procedure, ensuring the client’s safety.
C: Using the thumb and index finger to keep the client’s mouth open is not safe or effective. A mouth prop or padded tongue blade should be used instead.
D: Using a stiff toothbrush can cause damage to the gums and oral tissues. A soft-bristled toothbrush is recommended for gentle and effective cleaning.
Correct Answer is C
Explanation
A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.
B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.
C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.
D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.
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