Exhibits

The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room.
Which 3 interventions should be performed first?

Place pillows around the bed rails to provide padding.

Watch the seizure activity and document the time and client movement.

Manually ventilate the client with a bag-valve mask (BVM).

Stop the IV fluids.

Increase the supplemental oxygen to 10 L/minute via nasal cannula.

Begin chest compressions.

Answer and Explanation

Correct Answer : B,C,E

A.   This is important to prevent injury but is not the priority at this time.
B.   This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C.   This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D.   This is not necessary at this point and may not be feasible during the emergency situation.
E.   While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F.   Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

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Correct Answer is A

Explanation

A. Administering an incorrect dose of insulin can lead to hypoglycemia, a serious complication. Discarding the incorrectly dialed dose ensures patient safety. Directly addresses the error and prevents potential harm.
B. This option is inefficient and increases the risk of error. It's unnecessary to use both a pen and a syringe for a single dose. Does not address the immediate issue of the incorrect dose.
C. Administering more insulin than prescribed is dangerous and can lead to hypoglycemia. Wasting the remainder doesn't address the core issue of the incorrect dose. Increases the risk of hypoglycemia.
D. Insulin pens are designed to be precise. Dialing down to the correct dose after an error can compromise the accuracy of the dose. Does not ensure accurate dosing.

A. Assist the client with learning how to set priorities and pace activities. B. Instruct the client about the importance of maintaining bedrest. C. Consult the discharge planner about transferring the client to an assisted living center. D. Offer assurance that the fatigue inducing stage of the disease does not last.

Correct Answer is A

Explanation

A. RA often causes joint pain and stiffness, which can make it challenging to complete daily activities. Teaching the client how to set priorities and pace their activities helps them balance exertion with rest, thus reducing fatigue and improving overall function. This approach supports effective management of their condition by preventing overexertion and allowing time for recovery.
B. While rest is important for managing fatigue, strict bedrest is generally not recommended for RA patients. Prolonged bedrest can lead to muscle weakness, joint stiffness, and decreased mobility. Active management through appropriate rest and activity is usually more beneficial than complete bedrest.
C. Transferring to an assisted living center may be appropriate for some clients, but this intervention is not necessarily related to managing fatigue due to rheumatoid arthritis in the current context. This
decision would typically depend on the overall level of care needed and the client’s living situation.
D. While providing reassurance is part of supportive care, it’s important to address the specific needs and management strategies for fatigue. Simply offering assurance without practical interventions may not effectively address the client’s current symptoms or help them manage their condition in the long
term.

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Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

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Naxlex Comprehensive Predictor Exams

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse establishes a nursing problem of "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

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The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

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Exhibits

The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room.
Which 3 interventions should be performed first?