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 {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure

Rationale

The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.

A. Prepare to administer a glucose, then insulin, then potassium infusion. B. Inform the healthcare provider of the need for potassium replacement. C. Instruct the client to Increase dally Intake of potassium rich foods. D. Change the plan of care to Include hourly urinary output measurements.

Correct Answer is B

Explanation

A. This action is typically used in the treatment of hyperkalemia (high potassium levels), not hypokalemia. The combination of glucose and insulin is used to temporarily drive potassium into cells and lower serum potassium levels. For severe hypokalemia, the priority is to administer potassium replacement therapy rather than attempting to lower potassium levels, as the client needs to correct the deficiency.
B. Severe hypokalemia requires prompt correction to prevent complications. Potassium replacement should be administered according to healthcare provider orders. This may involve oral or intravenous potassium supplements, depending on the severity of the hypokalemia and the client's condition. Informing the healthcare provider is essential for ensuring that appropriate and timely treatment is provided.
C. While increasing potassium intake through diet is important for managing mild cases of hypokalemia, a serum potassium level of 2.5 mEq/L is severe and likely requires immediate medical intervention. Dietary changes alone are insufficient and not timely enough to address such a critical deficiency.
D. Monitoring urinary output is important in managing electrolyte imbalances to assess kidney function and fluid balance, but it is not the primary intervention for severe hypokalemia. The immediate priority is to address the low potassium level through appropriate replacement therapy.

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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

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

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?

The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

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A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

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?