A nurse is assisting a client to ambulate when the client begins to have a generalized seizure, identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Turn the client's head to the side

Guide the client to the floor.

Provide supplemental oxygen

Provide hygiene.

Initiate reorientation

Answer and Explanation

The Correct Answer is B,A,C,D,E

A. Turn the client's head to the side: Turning the head to the side helps maintain airway patency and allows saliva or secretions to drain, reducing the risk of aspiration. This action is performed once the client is safely positioned and seizing. Airway protection is a priority during active seizure activity.

B. Guide the client to the floor: Safely guiding the client to the floor prevents injury from a fall during sudden loss of muscle control. This is the first priority when a seizure begins during ambulation. Protecting the client from trauma takes precedence over all other actions.

C. Provide supplemental oxygen: After the seizure activity subsides, oxygen may be needed to address hypoxia caused by impaired breathing during the seizure. Supplemental oxygen supports adequate tissue oxygenation during the postictal phase. This action follows airway positioning and stabilization.

D. Provide hygiene: Hygiene care is provided after the seizure once the client is stable, as incontinence or excessive secretions may have occurred. Maintaining cleanliness promotes comfort and dignity. This step is not urgent and is addressed after physiologic needs are met.

E. Initiate reorientation: Reorientation is performed last, during the postictal phase, when the client may be confused or disoriented. Calm reassurance and simple explanations help reduce anxiety and support neurologic recovery. This action is appropriate only once the client is alert and stable.

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Correct Answer is A

Explanation

A. Blurred vision: Blurred vision during the third trimester can indicate a serious complication such as preeclampsia, which requires immediate reporting. It may signal elevated blood pressure and possible central nervous system involvement. Prompt communication with the provider is essential for maternal and fetal safety.

B. Leg cramps: Leg cramps are a common discomfort during pregnancy due to changes in circulation and pressure from the growing uterus. While uncomfortable, they are not considered an urgent finding that requires reporting.

C. Urinary frequency: Increased urinary frequency is typical in the third trimester as the enlarging uterus places pressure on the bladder. This is expected and usually does not indicate a complication unless accompanied by other symptoms such as pain or dysuria.

D. Gingivitis: Hormonal changes during pregnancy can lead to gum inflammation and bleeding. While oral care should be reinforced, gingivitis is a common, non-urgent finding and does not require immediate reporting to the provider.

A. Auscultate the client's lung sounds. B. Check the client's weight C. Check the client's apical pulse D. Obtain the clients oxygen saturation

Correct Answer is C

Explanation

A. Auscultate the client's lung sounds: While assessing lung sounds is an important part of the overall assessment for a client with heart failure (to check for pulmonary edema/crackles), it is not a specific requirement for the administration of digoxin. It helps evaluate the effectiveness of the treatment over time but does not determine if the current dose is safe to give.

B. Check the client's weight: Daily weights are essential for monitoring fluid volume status in heart failure patients. However, like lung sounds, this is an assessment of the disease progression rather than a safety check for the medication's immediate effect on the heart's electrical system.

C. Check the client's apical pulse: Digoxin can cause bradycardia and other arrhythmias. The nurse must assess the apical pulse for a full minute before administration and withhold the medication if the rate is below the provider’s prescribed parameters (commonly <60 bpm in adults).

D. Obtain the client's oxygen saturation: Oxygen saturation provides information about respiratory status but does not directly influence the decision to administer digoxin.

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A nurse is assisting a client to ambulate when the client begins to have a generalized seizure, identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the nurse take prior to administering this medication?

Correct Answer is C

Explanation

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