A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client’s head.

Insert a padded tongue blade into the client’s mouth.

Apply a face mask for oxygen administration.

Gently restrain the client’s extremities.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Place a pillow under the client’s head: During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.

Choice B reason:

Insert a padded tongue blade into the client’s mouth: This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.

Choice C reason:

Apply a face mask for oxygen administration: While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.

Choice D reason:

Gently restrain the client’s extremities: Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.

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Free Nursing Study Resources

Correct Answer is ["5"]

Explanation

Step 1: Determine the total volume to be infused. = 1 liter (L)

Step 2: Convert the total volume from liters to milliliters (mL). Calculation: 1 L × 1000 mL/L = 1000 mL

Step 3: Determine the infusion rate. = 200 mL/hr

Step 4: Calculate the infusion time in hours. Calculation: 1000 mL ÷ 200 mL/hr = 5 hours

Step 5: Round the answer to the nearest whole number if necessary. = 5 hours (no rounding needed)

The nurse should expect the IV pump to infuse over 5 hours.

A. Use wool blankets on your bed. B. Do not adjust the oxygen flow rate. C. Store unused oxygen tanks horizontally. D. Check your oxygen equipment once each week.

Correct Answer is B

Explanation

Choice A reason: Use Wool Blankets on Your Bed

Using wool blankets is not recommended for clients on home oxygen therapy. Wool and other materials that can generate static electricity pose a fire hazard when used around oxygen. Instead, clients should use cotton or other non-static generating materials to reduce the risk of fire.

Choice B reason: Do Not Adjust the Oxygen Flow Rate

This statement indicates an understanding of the teaching. Clients should not adjust the oxygen flow rate unless instructed by their healthcare provider. The prescribed flow rate is set to meet the client’s specific needs, and any changes could lead to inadequate oxygenation or other complications.

Choice C reason: Store Unused Oxygen Tanks Horizontally

This statement is incorrect. Oxygen tanks should be stored upright and secured to prevent them from falling over. Storing tanks horizontally can increase the risk of damage and potential leaks, which can be hazardous.

Choice D reason: Check Your Oxygen Equipment Once Each Week

While it is important to regularly check oxygen equipment, doing so only once a week may not be sufficient. Clients should check their equipment daily to ensure it is functioning properly and to identify any issues that need to be addressed promptly.

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A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["5"]

Explanation

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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