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 C

Explanation

C. Oliguria can occur in severe cases of left-sided heart failure. When the heart's ability to pump blood forward is compromised, blood flow to the kidneys decreases, leading to decreased urine production.
A. Pedal edema is more commonly associated with right-sided heart failure.
B. Neck vein distention is typically associated with right-sided heart failure where increased pressure in the right side of the heart leads to jugular venous distention
D. Enlarged liver, or hepatomegaly, can occur in right-sided heart failure due to congestion and backup of blood in the hepatic circulation.

A. Remains 3 feet away from the client B. Wears an N95 mask when providing wound care C. Disposes of isolation gown outside of the client's room D. Wears clean gloves when caring for the client

Correct Answer is D

Explanation

MRSA is spread through direct contact with infected persons or infectious droplets.
A. Keeping a safe distance is important but 3 feet away is not enough precaution.
B. MRSA is not airborne and hence not prevented through wearing of masks
C. The isolation gowns should be disposed in designated areas to prevent the spread of the infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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