A nurse is assisting in the care of a client.

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
_
followed by
_
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.

i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.

ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.

Rationale for incorrect answers:

remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.

reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.

administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.

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Correct Answer is ["A","D","E"]

Explanation

A. Allergies: The client is allergic to latex and penicillin. Since surgery involves the use of gloves, tubing, and catheters (latex) and often includes prophylactic antibiotics (penicillin family), these allergies must be communicated and a "latex-free" environment/alternative antibiotics must be established to prevent anaphylaxis.

B. Oxygen saturation: The client's oxygen saturation is 96%, which is within the normal expected range (95% to 100%). This does not require immediate follow-up prior to the procedure.

C. Pain level: While the pain is high (8/10), this is an expected finding for acute appendicitis. It should be managed, but it is not a barrier to surgery in the same way as safety or legal concerns.

D. Dietary intake: The client reported eating toast at 0600. Surgery requires a client to be NPO (nothing by mouth) for a specific period (usually 6–8 hours) to reduce the risk of aspiration under anesthesia. The surgical team and anesthesiologist must be notified of the 0600 intake.

E. Informed consent: Although the surgeon obtained consent, the nurse notes that the client "expresses concerns about potential complications." If a client expresses doubt or a lack of understanding after signing, the nurse must notify the surgeon to return and provide further clarification before the procedure begins.

F. Blood pressure: The client's blood pressure is stable (124/80 mm Hg) and within normal limits; it does not require follow-up.

A. Suctioning a tracheostomy for a client who has a recent head injury B. Providing postmortem care for a client who has just died C. Changing a peripheral IV dressing for a client who is postoperative D. Administering vaginal cream to a client who has a vaginal infection

Correct Answer is B

Explanation

A. Suctioning a tracheostomy for a client who has a recent head injury: Incorrect. This is an invasive procedure requiring clinical judgment and sterile technique; it must be performed by a nurse.

B. Providing postmortem care for a client who has just died: Postmortem care (cleaning the body, positioning) is within the scope of practice for an AP.

C. Changing a peripheral IV dressing for a client who is postoperative: Assessment of an IV site and sterile dressing changes require the skills of a licensed nurse.

D. Administering vaginal cream to a client who has a vaginal infection: Medication administration is generally restricted to licensed personnel (RN/LPN).

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A nurse is assisting in the care of a client. Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is _____ followed by _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is scheduled for an appendectomy. The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

Correct Answer is ["A","D","E"]

Explanation

A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

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A nurse is assisting in the care of a client.

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
_
followed by
_
.