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- Place a tongue blade in the client’s mouth: This is unsafe and outdated.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 A
Explanation
A. Syringe: A syringe is essential for irrigating a stage 4 pressure injury to cleanse the wound thoroughly without causing trauma to the tissue. Proper irrigation helps remove debris and bacteria, promoting healing. A syringe allows controlled, gentle flushing of the wound bed, which is important in managing deep, complex wounds like stage 4 pressure injuries.
B. Tongue depressor: A tongue depressor is generally used to examine the throat and oral cavity and is not suitable for wound care. It lacks the precision and safety needed for wound cleaning or dressing application, especially for deep pressure ulcers.
C. Adhesive tape: Adhesive tape is used to secure dressings but is not a primary supply for wound care itself. In managing a stage 4 pressure injury, the priority is proper wound cleaning and dressing materials rather than just securing them, so adhesive tape is secondary.
D. Cotton-tipped applicator: Cotton-tipped applicators are commonly avoided in wound care because they can leave fibers in the wound bed and potentially cause trauma or infection. They are not recommended for cleaning or applying medication to deep pressure ulcers, where more sterile, gentle methods are needed.
Correct Answer is ["A","B","E","G"]
Explanation
A. Ensure the oxygen delivery system is at least 8 feet from any heat source: Oxygen is flammable, and this safety measure helps prevent fire hazards in the home environment.
B. Store the oxygen cylinder wrench with the oxygen tank: Keeping the wrench with the tank ensures quick and easy access in case the oxygen needs to be turned on or off during an emergency.
C. Adjust the oxygen flow rate as needed to ease breathing: Clients should never adjust oxygen flow independently; flow rate changes must be prescribed and monitored by the healthcare provider to prevent complications like oxygen toxicity or hypoventilation.
D. Take antibiotic medication with or without food: This varies by antibiotic. Cefazolin, for example, was given IV in the hospital, and the oral form prescribed for home use might require food to reduce GI side effects; instructions should be drug-specific.
E. Take steroid medication in the morning: Steroids mimic the body’s natural cortisol rhythm; taking them in the morning minimizes insomnia and other endocrine side effects.
F. Decrease the steroid dose each day: Steroid tapering must follow a specific provider-prescribed regimen. Improper tapering can lead to adrenal insufficiency or withdrawal symptoms.
G. Take antibiotics for 10 days: Completing the full antibiotic course, even if symptoms improve, helps prevent antibiotic resistance and ensures complete eradication of the infection.
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