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 A
Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
Correct Answer is A
Explanation
A. "Wear a face mask when working within 3 feet of a child who is infected." Influenza spreads through droplets, so wearing a face mask within 3 feet of an infected child helps prevent transmission.
B. "Administer antibacterial medication within 24 hr of the onset of symptoms." Influenza is caused by a virus, not bacteria, so antibacterial medications (antibiotics) are not effective. Antiviral medications (e.g., oseltamivir) may be given within 48 hours of symptom onset.
C. "Children should be considered infectious for 14 days after the onset of symptoms." . Children with influenza are most contagious 1 day before symptoms appear and up to 5 to 7 days after onset.
D. "Administer the influenza vaccine every 6 months." The influenza vaccine is given annually (once per year), not every 6 months.
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