Patient Data
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.
Manually ventilate the client with a bag valve mask (BVM).
Watch the seizure activity and document the time and client movement.
Increase the supplemental oxygen to 10 L/minute via nasal cannula.
Stop the IV fluids.
Begin chest compressions.
Correct Answer : A,B,C
Rationale for Correct Choices:
- Manually ventilate the client with a bag valve mask (BVM): The client’s oxygen saturation is critically low at 40% and respiratory rate is 4 breaths/min, indicating severe hypoventilation and imminent respiratory failure. Immediate ventilation support is essential to prevent hypoxic injury.
- Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client is at risk of injury from violent movements. Padding the bed rails protects the client from trauma while interventions are performed.
- Watch the seizure activity and document the time and client movement: Monitoring seizure duration and characteristics is critical for treatment planning and for communicating accurate information to the healthcare team. It also guides decisions about when to administer emergency medications.
Rationale for Incorrect Choices:
- Increase the supplemental oxygen to 10 L/minute via nasal cannula: A nasal cannula can only deliver a maximum of 6 L/minute of oxygen. The client's oxygen saturation is 40%, and a nasal cannula is not a high-flow oxygen delivery system.
- Stop the IV fluids: There is no immediate indication to stop IV fluids during a seizure unless they interfere with airway management. Maintaining IV access is important for medication administration.
- Begin chest compressions: Chest compressions are indicated only if the client is pulseless. The client's heart rate is 58 beats/minute, and there is no indication that the client is in cardiac arrest. The client is experiencing respiratory failure, not cardiac arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Usual activity after taking the multivitamin: Physical activity is important for bone health, but it does not provide direct information about the client’s nutrient intake from the multivitamin or its adequacy in preventing osteoporosis.
B. What time of day the multivitamin is taken: Timing may affect absorption of some nutrients slightly, but it is less critical than ensuring the multivitamin contains sufficient amounts of key nutrients such as calcium and vitamin D.
C. If the multivitamin is taken with a meal or snack: Taking vitamins with food can improve absorption and reduce gastrointestinal upset, but the priority is confirming that the multivitamin actually contains the required calcium to support bone health.
D. The amount of calcium in the multivitamin: Calcium intake is essential for preventing osteoporosis, especially in older adults. Determining the calcium content ensures that the client is meeting recommended dietary allowances and guides further supplementation if needed.
Correct Answer is D
Explanation
Rationale:
A. Alteration in nutrition related to poor dietary intake: Inadequate nutrition is important to address, especially given the client’s financial concerns, but it is not immediately life-threatening compared to potential neurological complications.
B. Alteration in comfort related to motor vehicle collision: Headache, blurred vision, vertigo, and nausea may affect comfort, but prioritizing comfort alone overlooks potential serious complications from a recent head injury.
C. Anxiety related to unknown outcome of automobile repairs: Financial or situational anxiety is present, but it does not pose an immediate threat to physical health and is lower priority compared to neurological assessment.
D. High risk for injury related to increased intracranial pressure: The combination of neuro symptoms and three weeks post-collision suggests a possible post-concussion syndrome or delayed intracranial complication. Prompt assessment and monitoring for increased intracranial pressure are the priority to prevent serious neurological injury.
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