A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Loosen the client's clothing.

Help the client lie on the floor.

Turn the client onto their side.

Move items in the room away from the client.

Answer and Explanation

The Correct Answer is B

A. Loosen the client's clothing:
While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.
B. Help the client lie on the floor:
This is the correct answer. When a client is having a seizure, the priority is to ensure their safety. Lying the client on the floor helps prevent injury during the seizure, reducing the risk of falling from a chair or bed. Placing the client in a lateral (side) position can also help maintain an open airway.
C. Turn the client onto their side:
This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.
D. Move items in the room away from the client:
While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.

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Correct Answer is B

Explanation

Correct answer: B

A. Use a quick-release knot to secure the ties:

This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.

B. Cut the old ties after the new ties are secured:

This is the safest approach. It ensures the tracheostomy tube remains secure throughout the change.

C. Allow space for three fingers under the ties when securing:

Two fingers is the recommended space to allow for breathing comfort and prevent the tube from being too loose..

D. Extend the client's neck while securing the ties:

This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.

A. Place the sterile field at the level of the nurse's hips. B. Pour liquids into containers outside the sterile field. C. Hold bottles of sterile solution with the label in the palm of the hand. D. Open the outermost flap of the sterile kit toward the body.

Correct Answer is C

Explanation

A. Place the sterile field at the level of the nurse's hips:

This is incorrect. The sterile field should be placed at a waist or chest level to maintain its sterility. Placing it at the level of the nurse's hips increases the risk of contamination from airborne particles, clothing, or unsterile surfaces.

B. Pour liquids into containers outside the sterile field:

This is incorrect. Pouring liquids into containers outside the sterile field may lead to contamination. All actions involving sterile items should be performed within the sterile field to maintain its integrity and prevent the introduction of microorganisms.

C. Hold bottles of sterile solution with the label in the palm of the hand:

Hold bottles of sterile solution with the label in the palm of the hand:This is correct. This prevents label from becoming wet and illegible.

D. Open the outermost flap of the sterile kit toward the body:

Open the outermost flap of the sterile kit toward the body:This is incorrect. When opening a sterile kit, the nurse should open the outermost flap first and away from the body. This minimizes the risk of reaching over the sterile field, reducing the chance of accidental contamination.

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A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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