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?
Document the time the seizure began.
Turn the client's head to the side.
Loosen the clothing around the client's waist.
Check the client's motor strength.
The Correct Answer is B
A. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.
B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.
C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.
D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Drinking 8 cups of liquid daily is a correct measure to help flush out bacteria and prevent UTIs.
B. Wiping from back to front can increase the risk of transferring bacteria from the rectal area to the urethra; the correct practice is to wipe from front to back.
C. Regular and complete bladder emptying helps reduce the risk of bacterial growth in the urinary tract.
D. Drinking apple cider vinegar is not a standard recommendation for preventing UTIs; more evidence-based practices should be emphasized.
Correct Answer is A
Explanation
A. Airway obstruction is the priority because burns to the head, neck, and chest can compromise the airway due to swelling, soot, and edema. Immediate assessment and intervention are critical to ensure the airway remains patent and to prevent respiratory distress.
B. While infection is a significant risk in burn patients, addressing airway concerns takes precedence to prevent immediate life-threatening complications.
C. Paralytic ileus is a concern in burn patients but is less immediate compared to the risk of airway obstruction.
D. Fluid imbalance is crucial in burn management, but ensuring a clear airway is the immediate priority to prevent severe complications such as asphyxia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.