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.

Answer and Explanation

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

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Correct Answer is A

Explanation

Rationale for A:

A small hematoma at the catheter insertion site is common after cardiac catheterization due to the puncture of blood vessels. The nurse should inform the client that this may occur but reassure them that it typically resolves on its own.

Rationale for B:

The dressing usually remains intact for 24 to 48 hours post-procedure to prevent infection and promote healing. The client should be instructed to keep the dressing clean and dry until the healthcare provider gives specific instructions.

Rationale for C: Clients are usually advised to avoid strenuous activities and exercise for several days after the procedure, not to resume regular exercise the next day.

Rationale for D: Pain medication may be necessary to manage discomfort post-procedure, and the nurse should encourage the client to take pain relief as needed.

A. Exercise at least three times per week. B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. C. Take diuretics early in the morning and before bedtime. D. Take naproxen for generalized discomfort.

Correct Answer is A

Explanation

a.This is appropriate as regular, moderate exercise can help improve cardiovascular health and functional capacity in clients with heart failure. It is essential to discuss appropriate types and levels of exercise based on the individual’s condition.

b.This is incorrect because clients should be instructed to notify the provider if they gain 1 kg (2.2 lbs) in one day or 2 kg (4.4 lbs) in one week. A weight gain of 0.5 kg is not typically a threshold for concern.

c. Take diuretics early in the morning and before bedtime is wrong because it may disrupt the client's sleep patern and cause nocturia. The nurse should advise the client to take diuretics early in the morning and avoid taking them in the evening or at night, unless prescribed otherwise.

d. Take naproxen for generalized discomfort is wrong because naproxen is a nonsteroidal anti-inﬂammatory drug (NSAID) that can worsen heart failure by causing sodium and water retention, increasing blood pressure, and reducing the eﬀectiveness of diuretics and other heart failure medications. The nurse should advise the client to avoid NSAIDs and use acetaminophen or other alternatives for pain relief, as prescribed by the provider.

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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?

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Naxlex Comprehensive Predictor Exams

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