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 ["A","C","D","E","G"]

Explanation

Improvement in blood pressure would suggest better cardiovascular stability

A stable or decreased respiratory rate would indicate improved respiratory function and potentially reduced chest tightness.

An increase in oxygen saturation levels would indicate improved respiratory function and cardiovascular status.

A decrease in pain level would indicate improvement in the chest tightness and radiating pain experienced by the client.

A decrease in heart rate may indicate improved cardiovascular function and reduced stress on the heart.

Urinary output and echocardiogram results are not typically immediate indicators of improvement in the client's condition following an episode of chest tightness and radiating pain.

A. The client has 100 mL blood in the closed-suction drain. B. The client has an oral temperature of 38.3° C (100.9° F). C. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site. D. The client's capillary refill in the left toe is 6 seconds.

Correct Answer is D

Explanation

D. Capillary refill time greater than 2 seconds suggests impaired peripheral circulation, which could indicate vascular compromise or inadequate perfusion to the extremity. In a client with an external fixator, compromised circulation could lead to serious complications such as compartment syndrome or tissue necrosis.
A. This finding may be within the expected range for drainage following surgery, particularly if the client has undergone orthopedic surgery involving the placement of an external fixator. However, the nurse should continue to monitor the drainage and assess for any signs of increased bleeding or hematoma formation.
B. While a low-grade fever alone may not require immediate intervention, the nurse should assess the client further for other signs and symptoms of infection, such as increased pain, redness, warmth, or drainage at the surgical site.
C. While the client's pain level of 7 may require intervention to manage discomfort, it does not necessarily indicate an immediate threat to the client's safety or well-being.

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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

The nurse is reviewing the client's medical record. Exhibits Which of the following findings indicates the client's condition has improved? Select all that apply.

Correct Answer is ["A","C","D","E","G"]

Explanation

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Correct Answer is D

Explanation

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