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?

Choice A reason:

The first step in removing an NG tube is to verify the provider’s prescription to discontinue the tube. This ensures that the removal is authorized and appropriate for the client’s current condition.

Choice B reason:

Disconnecting the tube from the wall suction is an important step, but it should be done after verifying the provider’s prescription. This step prevents any suction-related complications during the removal process.

Choice C reason:

Performing hand hygiene is crucial to prevent infection, but it is not the first step. Hand hygiene should be performed after verifying the provider’s prescription and before touching the client or any equipment.

Choice D reason:

Providing mouth care to the client is important for comfort and hygiene, but it is not the first step in the process of removing an NG tube. This can be done after the tube has been safely removed.

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.