A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client on their side.

Perform a neurologic check.

Obtain the client's vital signs.

Notify the rapid response team.

Answer and Explanation

The Correct Answer is A

A.   Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B.   While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C.   While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D.   Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.

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Correct Answer is B

Explanation

B. Ondansetron is a commonly used medication for preventing nausea and vomiting induced by chemotherapy. It belongs to a class of drugs called serotonin receptor antagonists, which work by blocking serotonin receptors in the brain and gastrointestinal tract, thereby reducing the sensation of nausea and the urge to vomit. Ondansetron is often administered prior to chemotherapy to help prevent these side effects.
A. Diphenhydramine works by blocking histamine receptors in the brain that trigger nausea and vomiting. However, it is not commonly used as a first-line antiemetic for chemotherapy-induced nausea and vomiting.
C. Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant and is not used specifically for preventing chemotherapy-induced nausea and vomiting.
D. Methylprednisolone is a corticosteroid medication that has anti-inflammatory and immunosuppressant effects.

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply a vest restraint daily at bedtime to prevent nighttime wandering. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply soft heel protectors bilaterally while client is in bed.

Correct Answer is B

Explanation

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

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A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

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