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?

Place protective padding between the client and bed rails.

Provide privacy for the client during the event.

Observe the client's behavior during the event.

Record the client's level of consciousness after the event.

Answer and Explanation

The Correct Answer is A

A.   Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B.   Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C.   Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D.   Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

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Correct Answer is C

Explanation

A. Deep breathing and coughing are important for general postoperative care but they are not specifically indicated for immediate postoperative cataract surgery. These exercises can increase intraocular pressure and potentially disrupt the healing process.
B. While it's important to educate caregivers about medication administration, this is not the priority in the immediate postoperative period. The patient should be stable and comfortable before teaching begins.
C. An eye shield is crucial to protect the operated eye from accidental injury during sleep. It prevents rubbing and potential complications.
D. Monitoring vital signs is essential for postoperative care. However, the frequency of every 2 hours is excessive for cataract surgery. Vital signs can be monitored less frequently, depending on the patient's condition.

A. Increase the client's oxygen to 6 liters/minute. B. Obtain a stat arterial blood gas. C. Lower the bed to a semi-Fowler's position. D. Encourage the client to use pursed-lip breathing.

Correct Answer is B

Explanation

A. Increasing oxygen flow might seem like an immediate response, but it's crucial to be cautious with oxygen therapy in COPD patients. They often have a chronic CO2 retention issue, and excessive oxygen can sometimes reduce their drive to breathe, potentially worsening their condition. The increase in oxygen should be based on specific clinical guidelines and patient response, rather than an automatic increase.
B. Obtaining a stat arterial blood gas (ABG) is an important diagnostic step to evaluate the client’s oxygenation, ventilation, and acid-base status. This can provide critical information on the severity of the dyspnea and guide further treatment. It’s an essential action, particularly in acute dyspnea, as it helps in understanding the underlying cause and tailoring appropriate interventions.
C. The client is already in a high-Fowler’s position, which is optimal for improving lung expansion and easing dyspnea. Lowering the bed to a semi-Fowler’s position might not provide additional relief and could potentially worsen the client’s dyspnea. High-Fowler's position is generally preferred for severe dyspnea as it maximizes lung expansion and facilitates breathing.
D. Pursed-lip breathing is a helpful technique for managing dyspnea in COPD patients. It helps to prolong exhalation, reduce airway collapse, and improve gas exchange. This technique can provide immediate relief by helping the client control their breathing and reduce feelings of breathlessness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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