While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Observe for prolonged periods of apnea.

Observe for lacerations to the tongue.

Document details of the seizure activity.

Evaluate for evidence of incontinence.

Answer and Explanation

The Correct Answer is A

A.   This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
B.   This intervention is crucial for assessing potential injury to the client's mouth or tongue, which can occur during a seizure due to involuntary muscle movements. However, before assessing for lacerations, the nurse should prioritize ensuring the client's safety.
C.   Documenting details of the seizure activity is important for maintaining accurate medical records and providing information to the healthcare team. However, before documenting details of the seizure, the nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure. Therefore, while documentation is essential, it may not be the first intervention to implement.
D.   While evaluating for incontinence is important for addressing the client's immediate needs and ensuring comfort, it may not be the first intervention to implement. The nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure.

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Correct Answer is A

Explanation

A. A high-pitched sound heard upon inspiration, known as a "stridor," can indicate airway obstruction or respiratory distress. In the postoperative period following an appendectomy, airway patency and adequate ventilation are essential for the client's oxygenation and recovery.
B. While a slightly elevated heart rate may be expected in the immediate postoperative period due to stress or pain, it does not typically require immediate action unless accompanied by other concerning symptoms.
C. Redness and edema at the incision site can be normal inflammatory responses following surgery.
D. Pain is common after surgery, and a pain rating of 8 on a scale of 0 to 10 indicates moderate to severe pain.

A. Replace transdermal analgesic patches every 72 hours. B. Administer analgesics on a fixed and continuous schedule. C. Monitor client for break through pain. D. Frequently evaluate the client's pain.

Correct Answer is C

Explanation

C. Breakthrough pain is a transient exacerbation of pain that occurs despite the use of around- the-clock analgesics for persistent pain. Breakthrough pain episodes require rapid intervention with additional analgesics or adjustments to the current pain management regimen to provide adequate pain relief and improve the client's quality of life.
A. Replacing transdermal analgesic patches every 72 hours is important for ensuring consistent delivery of medication, but it is not directly related to addressing breakthrough pain.
B. Administering analgesics on a fixed and continuous schedule is important for maintaining baseline pain control, but it may not address breakthrough pain adequately.
D. Frequently evaluating the client's pain is essential, but monitoring specifically for breakthrough pain ensures timely intervention when pain exacerbations occur.

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While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Correct Answer is A

Explanation

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

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