A head-injured patient is presenting with a generalized seizure. An appropriate nursing intervention during the seizure would include which of the following?
Loosen the patient's restrictive clothing.
Open the patient's jaws to insert an oral airway.
Restrain the patient to prevent injury.
Place patient in high-Fowler's position.
The Correct Answer is A
A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.
B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.
C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.
D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.
B. Hemolytic – Correct Answer. A hemolytic reaction occurs when the immune system attacks transfused red blood cells due to incompatibility. Symptoms include fever, chills, hypotension, back pain, and hematuria (red-tinged urine). This is a medical emergency requiring immediate intervention.
C. Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.
D. Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.
Correct Answer is A
Explanation
A. Regular insulin is the only insulin type that can be administered intravenously and is used in DKA treatment.
B. Lantus (glargine) is a long-acting insulin and is not used in acute situations.
C. Mixed insulins (intermediate and short-acting) are not appropriate for IV administration.
D. NPH is an intermediate-acting insulin and is not suitable for IV use.
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