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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Add liquid to foods to thin consistency.: Thin liquids are actually the most difficult to swallow and increase the risk of aspiration. Foods should be thickened to a "nectar" or "honey" consistency as prescribed.
B. Tilt the client's head slightly backward.: This opens the airway. For safe swallowing, the client should use the "chin-tuck" method (tilting the head forward/down) to help close the trachea and open the esophagus.
C. Encourage socialization with others during meals.: Clients with dysphagia should focus entirely on chewing and swallowing to prevent aspiration; talking while eating increases risk.
D. Provide mouth care before the client eats.: Oral hygiene before meals stimulates the appetite and removes bacteria from the mouth. If a client does aspirate, they are less likely to develop pneumonia if their oral cavity is clean.
Correct Answer is C
Explanation
A. Mark the length to be inserted on the tube with tape.: This is done after the pathway is assessed but before insertion.
B. Place a water-based lubricant on the tip of the tube.: This is done immediately before insertion, not as the first step.
C. Compare the patency of the client's nares.: Following the Nursing Process (Assessment first), the nurse must determine which nostril is most patent to ensure the easiest passage for the tube.
D. Instruct the client to hyperextend her neck.: This is a position used during the initial insertion phase, but assessment of the nares must come first.
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