The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?

Activates the rapid response team (RRT).

Loosens any restrictive clothing.

Places the client in a lateral position.

Prepares to administer intravenous valproate acid.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Activates the rapid response team (RRT) - Status epilepticus is a medical emergency requiring immediate intervention. Activating the rapid response team would ensure a prompt response to the situation.

Choice B rationale: Loosens any restrictive clothing - It is important for patient safety and comfort.

Choice C rationale: Places the client in a lateral position - This is a recommended positioning to prevent aspiration during a seizure.

Choice D rationale: Prepares to administer intravenous valproate acid - Valproic acid is not the first drug during epilepsy hence this action would necessitate immediate intervention.

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Correct Answer is A

Explanation

Choice A rationale: Gloves should be worn during direct contact with the client's skin. This is a standard precaution that applies to all clients, but especially to those with infectious diseases that can be transmitted through contact. Secondary syphilis is highly contagious and can be spread through direct contact with the skin lesions or mucous

membranes of an infected person.

Choice B rationale: This is incorrect because secondary syphilis requires more than standard precautions to prevent transmission.

Choice C rationale: This is incorrect because handwashing is a basic component of standard precautions and is not sufficient to prevent the spread of syphilis.

Choice D rationale: This is incorrect because a mask is not necessary for contact precautions, unless the client has respiratory symptoms or is undergoing aerosol- generating procedures.

A. Determine if blood is present in urine B. Perform a neurological assessment C. Administer IV normal saline D. Perform a 12-lead electrocardiogram

Correct Answer is C

Explanation

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

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The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with multiple traumas after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement?

Correct Answer is A

Explanation

The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Correct Answer is C

Explanation

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