A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Turn the child onto their back.

Restrain the child's upper extremities.

Place a padded tongue blade in the child's mouth.

Place a pillow under the child's head.

Answer and Explanation

The Correct Answer is D

The correct action to take in this situation is to place a pillow or cushion under the child's head.

This will help protect the child from injuring their head during the seizure.

It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.

Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.

Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.

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Correct Answer is C

Explanation

Using a cool-mist vaporizer in the baby's room can help provide moisture and relieve nasal congestion, especially during cold or dry weather. It can help ease breathing and improve the baby's comfort.

"I will leave the plastic covering on the crib mattress": This statement is incorrect. The plastic covering should be removed from the crib mattress before placing the baby in the crib. The plastic covering poses a suffocation risk and should not be used.

"I will lay my baby's head on a pillow while he is in the crib": This statement is incorrect. Pillows should not be used in the crib for infants. They increase the risk of suffocation and can pose a hazard to the baby. The crib should be free of pillows, blankets, stuffed animals, or any other loose items.

"I will leave my baby's bib on while he is sleeping": This statement is incorrect. Bibs should be removed before placing the baby in the crib or while the baby is sleeping to prevent the risk of suffocation. Loose items around the baby's neck can pose a strangulation hazard.

A. A nurse observes a client vomiting after receiving an oral pain medication. B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. C. A nurse discovers that an electronic IV pump.delivered twice the prescribed amount of fluid to a client. D. A nurse discovers that a client's family member has administered a PCA dose.

Correct Answer is C

Explanation

This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.

The following examples may not require an incident report:

A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.

A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.

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A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

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