A nurse is assisting in the care of a client.
Complete the following sentence:
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":"D"}
At 1000, when the nurse enters the client's room and the client is experiencing an aura followed by generalized jerking contractions of arms and legs, the first action the nurse should take is to ensure the client's safety. This includes removing any potential hazards from the immediate vicinity, such as pillows that could obstruct the airway or cause suffocation.
The next critical action is to turn the client to their side, which helps maintain an open airway, allows for any secretions to drain, and reduces the risk of aspiration should vomiting occur. These steps are vital in managing a seizure and are part of the standard care procedures to protect the client during and after a seizure episode.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The stoma bleeds lightly when touched: Light bleeding is common postoperatively and may not be concerning unless it's excessive or persistent.
B. The stoma is draining a small amount of liquid stool: This is a normal finding following colostomy placement and is expected in the early postoperative period.
C. The stoma appears dark in color: This may indicate compromised blood supply to the stoma and requires immediate evaluation by the provider.
D. The stoma protrudes slightly from the abdomen: This is a normal finding post-colostomy and does not typically require immediate intervention.
Correct Answer is ["B","C"]
Explanation
A. Squeezing the client's finger until a blood drop forms can result in hemolysis and inaccurate results; instead, gentle milking or massaging of the finger is recommended.
B. Applying clean gloves is necessary to maintain infection control practices.
C. Pricking the side of the client's finger is the appropriate technique for obtaining a capillary blood specimen.
D. Elevating the client's hand above the level of the heart is not necessary and may impede blood flow.
E. Cleansing the client's finger with an iodine swab helps to disinfect the area prior to obtaining the blood specimen.
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