A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?
Apply oxygen by nasal cannula.
Administer an anticonvulsant medication.
Turn the client to a lateral position.
Check the client's oxygen saturation.
The Correct Answer is C
C. The priority during a seizure is to protect the patient from harm, particularly from aspiration if they vomit or have excessive saliva production. Turning the client to a lateral position helps maintain an open airway and prevents aspiration. This action should be taken immediately after lowering the client to the floor to ensure their safety.
A. Providing oxygen is important for a patient experiencing a seizure. However, it's not the first action to take. The priority is to ensure the patient's safety and protect them from injury during the seizure.
B. Administering anticonvulsant medication during an active seizure is not appropriate. Anticonvulsants are typically prescribed as maintenance therapy to prevent seizures or to manage seizure disorders in a controlled manner, not during an acute seizure episode.
D. Monitoring oxygen saturation is important but it's not the first action to take during an active seizure. Ensuring the patient's safety and protecting them from injury take precedence. Oxygen saturation can be assessed once the patient is in a safe position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should ensure that the rope knots are positioned away from the pulleys to prevent interference with the traction mechanism. Proper alignment of the rope and pulleys ensures smooth traction application and prevents accidental slippage or dislodgment of the traction weights.
A. Buck's traction typically does not involve pin sites. It involves the application of traction to the affected limb using a boot or traction tape. Antibiotic ointment is not typically applied to the skin under Buck's traction unless there are specific wounds or abrasions that require treatment.
C. Ensuring the child's feet are against the footboard is not applicable to Buck's traction, which does not require the feet to be against a footboard.
D. There is typically no need to reduce a child's fluid intake solely because they are in Buck's traction for Legg-Calve-Perthes disease. Adequate hydration is essential for overall health and healing, and fluid restriction is not indicated unless there are specific medical reasons for doing so.
Correct Answer is C
Explanation
C. Clubbing, characterized by bulbous enlargement of the fingertips and nail bed, is a result of chronic hypoxia in tetralogy of Fallot. In tetralogy of Fallot, there is a right-to-left shunting of blood due to the presence of a ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. This leads to reduced oxygenation of blood and chronic hypoxia, which can result in clubbing of the fingertips over time.
A This option is not the primary explanation for clubbing in tetralogy of Fallot. While decreased cardiac output may contribute to some manifestations of the condition, clubbing specifically results from chronic hypoxia rather than decreased cardiac output alone.
B Clubbing is not directly caused by a left-to-right shunting of blood. Instead, it is associated with chronic hypoxia, which can occur due to right-to-left shunting of blood in tetralogy of Fallot.
D Congestive heart failure may occur in individuals with tetralogy of Fallot but it is not the primary cause of clubbing. Clubbing in tetralogy of Fallot is primarily attributed to chronic hypoxia rather than heart failure alone.
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