A nurse is transporting a 12-year-old child in a wheelchair. The child begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take?
Insert an oral airway for the child.
Apply soft restraints to the child's wrists.
Place a pillow under the child's knees.
Move the child to the floor
The Correct Answer is D
A. Insert an oral airway for the child. Inserting an oral airway during a tonic-clonic seizure is not recommended, as it could cause injury to the child or block the airway. During a seizure, the priority is ensuring safety rather than trying to insert devices.
B. Apply soft restraints to the child's wrists. Restraints are not recommended during a seizure, as they can increase the risk of injury. Instead, the focus should be on protecting the child from injury and allowing the seizure to run its course.
C. Place a pillow under the child's knees. While positioning the child is important, placing a pillow under the knees is not a recommended action. The goal is to move the child to the floor to prevent falls or injury during the seizure.
D. Move the child to the floor. If a child is in a wheelchair and begins to have a seizure, moving them to the floor is the first step to prevent injury. Once the child is on the floor, ensure they are on their side to allow for airway clearance and reduce the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. "Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. "Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. "Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.
Correct Answer is B
Explanation
A. Heart rate – No data regarding heart rate is provided in the exhibit, so this is not a relevant option.
B. HbA1c – The child's HbA1c level is 8.5%, which is elevated above the normal range (4% to 5.9%). This indicates poor glycemic control, suggesting the development of cystic fibrosis-related diabetes (CFRD), a common complication of cystic fibrosis. This should be reported to the provider for further evaluation and management.
C. WBC count – The WBC count is 9,600/mm³, which is within the normal range (5,000 to 10,000/mm³), so it does not require reporting.
D. Oxygen saturation – No data regarding oxygen saturation is provided in the exhibit, making this option irrelevant.
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