A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's arms.
Administer a muscle relaxant.
Insert a tongue blade.
The Correct Answer is A
A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the client in a sitting position. A belt restraint should be applied while the client is in a sitting or supine position to minimize the risk of injury and ensure comfort. Proper positioning helps maintain respiratory function and circulation, reducing complications associated with prolonged immobility.
B. Ensure the restraint is placed across the client's chest. A belt restraint should be secured around the waist, not the chest, to prevent respiratory restriction. Placing it across the chest can impair breathing and increase the risk of asphyxiation, especially if the client struggles or shifts position.
C. Tie the restraint to the railing of the client's bed. Restraints should always be secured to the bed frame, never to the side rails, to prevent injury. Attaching restraints to side rails can cause excessive restriction or accidental tightening if the rails are adjusted, leading to discomfort or harm.
D. Apply the restraint under the client's clothes. Restraints should be placed over the client's clothing or gown to prevent skin irritation and pressure injuries. Applying a restraint directly against the skin increases the risk of friction, breakdown, and potential pressure ulcers over time.
Correct Answer is A
Explanation
A. Physicians' Desk Reference (PDR). The PDR is a comprehensive drug reference that provides essential information on medications, including indications, dosages, contraindications, adverse effects, and interactions. It is a reliable resource for nurses to review before administering an unfamiliar medication.
B. State Nurse Practice Act (NPA). The NPA defines the scope of nursing practice and legal responsibilities but does not provide specific drug information. While it guides nurses on legal and ethical aspects of medication administration, it is not a medication reference.
C. Agency for Healthcare Research and Quality (AHRQ). AHRQ focuses on improving healthcare quality and patient safety but does not serve as a primary source for drug-specific information. It provides guidelines and research on best practices rather than detailed medication data.
D. Quality and Safety Education for Nurses (QSEN). QSEN aims to improve nursing education and competency in patient safety but does not offer detailed drug reference materials. It emphasizes principles such as evidence-based practice and quality improvement rather than specific medication details.
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