The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next?
Begin chest compressions.
Watch the seizure activity and document the time and client movement.
Place pillows around the bed rails to provide padding.
Stop the IV fluids.
Increase the supplemental oxygen to 10 L/min via nasal cannula.
Manually ventilate the client with a bag-valve mask.
Correct Answer : C,E,F
C. Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client may experience uncontrolled movements and convulsions. Placing pillows around the bed rails helps prevent injury by providing padding and cushioning.
E. Increase the supplemental oxygen to 10 L/min via nasal cannula: The client's oxygen saturation is dangerously low at 40%. Increasing the supplemental oxygen to 10 L/min via nasal cannula will help improve oxygenation and prevent hypoxia.
F. Manually ventilate the client with a bag-valve-mask: Since the respiratory rate is only 4 breaths/min, the client is not adequately ventilating on their own. Manual ventilation with a bag-valve mask will provide necessary oxygenation and ventilation support during the seizure.
The other options are not appropriate actions at this time:
- Begin chest compressions: Chest compressions are indicated if the client's heart has stopped or if they are in cardiac arrest. Since the scenario describes a seizure, the client's heart is presumed to be functioning.
- Watch the seizure activity and document the time and client movement: Although documentation is important, during an active seizure, the priority is to ensure the client's safety and provide immediate interventions. Documentation can be done after the seizure has ended.
- Stop the IV fluids: There is no indication to stop the IV fluids based on the given information. IV fluids are generally continued unless there is a specific reason to discontinue them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gather the procedure tray and equipment – The practical nurse should gather all necessary supplies for the healthcare provider to perform the thoracentesis efficiently. Preparing the equipment beforehand ensures that the procedure can start promptly and reduces interruptions for missing supplies.
Rationale for Incorrect Answers:
B. Cleanse the site and cover with a sterile towel – This action should be performed by the healthcare provider immediately before the procedure to maintain sterility. The PN’s role is to prepare equipment and ensure the client is positioned correctly.
C. Keep the patient NPO (nothing by mouth) and encourage them to void – While voiding may be encouraged before some procedures to improve client comfort, it is not necessary for thoracentesis. Additionally, keeping the client NPO is not required, as the procedure does not typically involve sedation that would necessitate this restriction.
D. Place the patient in an orthopneic position – This may be done just before the procedure, but the healthcare provider typically directs the final positioning. Initial positioning or seating at the bedside can be done, but orthopneic positioning should follow the provider’s instructions.
Correct Answer is D
Explanation
Acne is a common skin condition that often requires specialized treatment. While general skin care practices can help maintain healthy skin, the most appropriate recommendation for a 16-year-old client seeking treatment for acne is to refer them to a dermatologist.
Acne can have various underlying causes, and effective treatment often involves a tailored approach based on the individual's specific condition. Dermatologists are medical professionals specializing in skin health and are best equipped to assess and provide appropriate treatment options for acne.
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