The nurse has reviewed the Provider Prescriptions at 1030, the Nurses' Notes at 1045 and 1100, and the Vital Signs at 1100.
Which of the following actions should the nurse take? Select all that apply.
Roll adolescent onto their side.
Do not restrain the adolescent.
Begin chest compressions.
Prepare to give phenytoin PO stat.
Suction the oral cavity.
Insert bite block.
Correct Answer : A,B,E
A. Rolling the adolescent onto their side is appropriate during seizure activity or altered consciousness to maintain an open airway and allow secretions or emesis to drain, reducing the risk of aspiration. This is part of standard seizure precaution care.
B. Not restraining the adolescent prevents musculoskeletal injury and does not interfere with involuntary seizure movements. Restraints can cause fractures, dislocations, or soft tissue injury and should be avoided during seizure activity.
C. Beginning chest compressions is not indicated, as the adolescent still has vital signs, a pulse, and spontaneous respirations. CPR would only be initiated if there was a confirmed absence of breathing and pulse.
D. Preparing to give phenytoin PO stat is not appropriate because the adolescent is NPO and at risk for aspiration. If anticonvulsants are required, the IV route would be used instead of oral administration.
E. Suctioning the oral cavity is appropriate to maintain airway patency and clear secretions that may accumulate during seizure activity or when the client is drowsy and unable to handle secretions effectively.
F. Inserting a bite block is unsafe during seizures, as it can break teeth, injure the mouth, or obstruct the airway. Nothing should be placed in the mouth once a seizure has started.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Initiate airborne precautions: Airborne precautions are not required for a child receiving gentamicin, as this antibiotic is not used for airborne infections such as tuberculosis or measles. Standard precautions are sufficient.
B. Maintain strict I&O: Gentamicin is nephrotoxic, and monitoring intake and output is essential to detect early signs of kidney impairment. Strict fluid balance assessment helps ensure prompt recognition of adverse renal effects.
C. Monitor for constipation: Constipation is not a typical adverse effect of gentamicin therapy. More concerning effects are nephrotoxicity and ototoxicity, which require close monitoring during treatment.
D. Encourage bed rest: Bed rest is not necessary during gentamicin therapy. Activity restrictions are not required unless dictated by the child’s underlying illness or other clinical factors.
Correct Answer is C
Explanation
A. Rolls over from abdomen to back: This milestone typically occurs around 4 months of age, not at 2 months. At 2 months, the infant’s motor skills are not yet developed enough for rolling over.
B. No head lag when pulled into a sitting position: Infants usually continue to have some head lag until about 4 months. At 2 months, head control is still limited, so absence of head lag would not be expected.
C. Lifts head 45° when lying prone: By 2 months, infants can momentarily lift their head and upper chest to about 45 degrees when placed on their stomach. This is an appropriate gross motor milestone for this age.
D. Rolls over from back to abdomen: This milestone usually develops later, around 6 months of age, when trunk and arm strength are more advanced. It is not expected at 2 months.
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