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 C
Explanation
Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the floor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.
Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Correct Answer is ["24"]
Explanation
To calculate the infusion rate, use the formula:
(rate in mL/hr) = (desired dose in units/hr) / (available dose in units/mL)
In this case, the desired dose is 1,200 units/hr and the available dose is 25,000 units / 500 mL = 50 units/mL. Therefore,
(rate in mL/hr) = (1,200 units/hr) / (50 units/mL) = 24 mL/hr
Round the answer to the nearest tenth/whole number and use a leading zero if it applies. Do not use a trailing zero because it could be misread as a decimal point. Therefore, the nurse should set the IV pump to deliver 24 mL/hr.
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