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"}
Rationale for Correct Answers:
- Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
- Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.
Rationale for Incorrect Answers:
- Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
- Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
- Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
Target 1: Paralytic ileus
- The client is 6 hours postoperative with hypoactive bowel sounds and no mention of flatus or stool. The use of IV opioids (morphine) increases the risk for reduced gastrointestinal motility. Paralytic ileus is common after abdominal surgery and with opioid use.
Target 2: Atelectasis
- The client has shallow bilateral breath sounds postoperatively, which indicates a risk for atelectasis, a common complication due to decreased mobility, pain limiting deep breathing, and effects of anesthesia.
Rationale for Incorrect Choices:
- Urinary tract infection: The client voided 350 mL of clear yellow urine after catheter removal with no signs of infection.
- Delayed wound healing: No signs of infection or poor wound healing; the dressing is dry and intact.
- Deep vein thrombosis: Though a risk postoperatively, the client is wearing SCDs and has even pedal pulses with no edema, lowering immediate concern.
Correct Answer is B
Explanation
A. Testicular examination: Testicular cancer screening is typically encouraged from adolescence to around age 35, as it is more common in younger men. Routine testicular exams are not specifically recommended starting at age 50.
B. Colonoscopy: Colorectal cancer screening, such as colonoscopy, should begin at age 45 or 50 for individuals at average risk. It is a key preventive measure for detecting colorectal cancer in its early stages.
C. Clinical breast examination: Clinical breast exams may be done earlier, typically starting in the 20s or 30s, depending on risk factors. They are not newly initiated at age 50.
D. Fasting blood glucose: Screening for diabetes may begin as early as age 35 in adults with risk factors. It is important but not specifically recommended as a new screening starting at age 50.
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