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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The primary purpose of maintaining an elastic bandage around the residual limb after a below-the- knee amputation is to provide compression and support, which helps minimize swelling (edema) of the residual limb. By reducing edema, the elastic bandage can promote proper wound healing, improve comfort, and facilitate the fitting of prosthetic devices in the future.
A. While maintaining proper wound care and hygiene can help prevent wound infections, an elastic bandage around the residual limb of a below-the-knee amputation primarily serves other purposes, such as providing compression and support, rather than directly preventing wound infections.
B. The purpose of an elastic bandage is not to conceal the surgical site. It is used primarily for compression, support, and minimizing swelling of the residual limb.
C. While an elastic bandage may help provide some pressure and support to the surgical site, its primary purpose is not to prevent sutures from loosening.
Correct Answer is C
Explanation
C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration
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