Which action should the nurse implement first?

Place the client on his side

Push aside any furniture

Assess the client's vital signs

Ease the client to the floor

Answer and Explanation

The Correct Answer is D

Choice A reason: While placing the client on their side is a recommended action to prevent aspiration, it is not the immediate first step. Ensuring the client's safety by lowering them to the floor is a more urgent priority to prevent injury during the seizure.

Choice B reason: Pushing aside any furniture is a good safety measure to prevent injury, but it is not the most immediate action. The primary concern during an active seizure is to protect the client from harm by easing them to the floor.

Choice C reason: Assessing vital signs is crucial but should be done after ensuring the client's immediate safety. During a seizure, the first priority is to prevent injury, which means easing the client to the floor comes first.

Choice D reason: The immediate first action is to ease the client to the floor to prevent them from falling and sustaining injuries. This step ensures that the client is in a safe position before other measures, such as placing them on their side or moving furniture, are taken.

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Correct Answer is C

Explanation

Choice A reason:

While 1 oz of orange juice can help raise blood glucose levels in conscious patients experiencing mild hypoglycemia, it is not appropriate for someone who is unconscious and difficult to arouse. Such clients cannot safely consume liquids orally due to the risk of aspiration.

Choice B reason:

Epinephrine is not used to treat hypoglycemia. It is typically administered during severe allergic reactions (anaphylaxis) or cardiac arrest. It does not address the immediate need to raise blood glucose levels in hypoglycemic patients.

Choice C reason:

IV dextrose 50% is the appropriate treatment for severe hypoglycemia in unconscious or lethargic patients. It provides a rapid increase in blood glucose levels and is administered intravenously, which is safe and effective for patients who cannot take oral glucose.

Choice D reason:

Glucose tablets can be used to treat mild to moderate hypoglycemia in conscious patients. However, they are not suitable for patients who are unconscious or difficult to arouse, as these patients cannot safely chew and swallow tablets without the risk of choking or aspiration.

A. Hypotension B. Blood clots C. Hypoglycemia D. Tongue discoloration

Correct Answer is D

Explanation

Choice A reason:

Hypotension is not a known adverse effect of bismuth subsalicylate. This medication primarily affects the gastrointestinal system and does not typically influence blood pressure.

Choice B reason:

Blood clots are not associated with bismuth subsalicylate use. This medication does not have effects on coagulation or blood clotting mechanisms.

Choice C reason:

Hypoglycemia is not a side effect of bismuth subsalicylate. It does not impact blood glucose levels, and clients do not need to be concerned about hypoglycemia when taking this medication.

Choice D reason:

Tongue discoloration is a common and benign side effect of bismuth subsalicylate. The medication can cause the tongue and stool to turn black temporarily. Clients should be informed about this effect to prevent unnecessary concern.

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Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is lethargic, unconscious, and difficult to arouse. The client's blood sugar result was 40 mg/dL. The nurse anticipates which of the following to be administered?

Correct Answer is C

Explanation

A client is currently taking bismuth subsalicylate (Pepto-Bismol) to help with diarrhea. The nurse would educate the client on which adverse effect associated with bismuth subsalicylate?

Correct Answer is D

Explanation

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

A nurse is caring for a client receiving phenazopyridine (Azo) for urinary tract analgesia. Which of the following side effects is associated with phenazopyridine?

A client newly prescribed niacin (Nicotinic Acid) presents to the healthcare setting with complaints of flushing following doses. Which of the following medications would the nurse anticipate being administered?

The nurse is caring for a client currently taking a combination birth control pill for contraception prevention. Which adverse effect would the nurse closely monitor for associated with this medication?

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

A nurse is teaching a client with a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use when experiencing an acute asthma attack?

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which client statement indicates a need for further teaching?