A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Place the client on their side with their head forward.

Administer an anticonvulsant medication.

Time the length of the client's seizure.

Loosen the client's gown and allow them to move freely.

Answer and Explanation

The Correct Answer is A

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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Correct Answer is A

Explanation

A. Orange slices: Orange slices should be avoided because they contain a fibrous membrane that can be difficult to chew and swallow, posing a choking risk. Additionally, the acidic nature of oranges may cause irritation in some clients.

B. Ground hamburger: Appropriate for a mechanical soft diet because it is easy to chew and swallow.

C. Cooked green beans: Softened through cooking, making them easy to chew.

D. Canned peaches: Soft and easy to chew, making them suitable for this diet.

A. Mix the medications together and administer through the NG tube. B. Crush the sublingual medication into powder form. C. Dissolve crushed tablet medications in sterile water. D. Flush the tube with 5 mL saline between each medication.

Correct Answer is C

Explanation

A. Mix the medications together and administer through the NG tube. Incorrect because medications should be given separately to prevent drug interactions and ensure each is fully delivered.

B. Crush the sublingual medication into powder form. Incorrect because sublingual medications are designed to be absorbed through the oral mucosa, not the gastrointestinal tract. Crushing them negates their intended action.

C. Dissolve crushed tablet medications in sterile water. Sterile water is preferred for dissolving medications because it reduces the risk of bacterial contamination and prevents potential drug interactions that may occur with other fluids.

D. Flush the tube with 5 mL saline between each medication. Incorrect because a minimum of 15-30 mL of water is recommended between medications to prevent tube blockage.

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