A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's extremities.
Apply a face mask for oxygen administration.
Insert a padded tongue blade into the client's mouth.
The Correct Answer is A
- Place a pillow under the client's head.
The nurse should place a pillow under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
- Gently restrain the client's extremities is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure, but rather ensure a safe environment and observe the seizure activity.
- Apply a face mask for oxygen administration is wrong because it can be dislodged by the client's movements and pose a choking hazard. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather provide oxygen by nasal cannula after the seizure if needed.
Insert a padded tongue blade into the client's mouth is wrong because it can damage the client's teeth, gums, or tongue, or cause aspiration or airway obstruction. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather turn the client to a side-lying position after the
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The P wave is the first wave on the ECG strip and represents the electrical activity of the atria. It reflects the depolarization of the atrial myocardium, which is the process of changing the electrical charge of the cardiac cells from negative to positive, triggering a contraction. The P wave precedes the QRS complex, which represents ventricular depolarization, and the T wave, which represents ventricular repolarization.
The other options are not correct because:
a. Slow repolarization of ventricular Purkinje fibers. This statement is incorrect because it describes the U wave, which is a small and sometimes invisible wave that follows the T wave on the ECG strip. It reflects the repolarization of the ventricular Purkinje fibers, which are specialized cardiac cells that conduct electrical impulses to the ventricles. The U wave is more prominent in conditions that cause hypokalemia, such as diuretic use or vomiting.
c. Early ventricular repolarization. This statement is incorrect because it describes the ST segment, which is the flat line between the QRS complex and the T wave on the ECG strip. It reflects the early phase of ventricular repolarization, which is the process of restoring the electrical charge of the cardiac cells to negative after a contraction. The ST segment can be elevated or depressed in conditions that cause myocardial ischemia or injury, such as angina or myocardial infarction.
d. Ventricular depolarization. This statement is incorrect because it describes the QRS complex, which is the largest and most visible wave on the ECG strip. It reflects the depolarization of the ventricular myocardium, which triggers a ventricular contraction. The QRS complex follows the P wave and precedes the T wave on the ECG strip.
Correct Answer is ["8"]
Explanation
To calculate the volume to administer, the nurse should use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL) x 1000
Plugging in the given values, the nurse should get:
Volume (mL) = 400 mg / 250 mg/5 mL x 1000
Volume (mL) = 8 mL
The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should administer 8 mL of valproic acid per dose.
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