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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gloves should be removed first to prevent contamination of the hands when removing other protective equipment.
B. The gown can be removed after gloves to prevent contamination of clothing underneath.
C. Goggles should be removed after gloves and gown to prevent contamination of the face.
D. The mask should be removed last to provide continued protection against airborne contaminants.
Correct Answer is D
Explanation
A. This response may be perceived as judgmental and could potentially worsen the client's anxiety or stress.
B. While involving the doctor may eventually be necessary, it's important for the nurse to first acknowledge and respect the client's decision.
C. Asking "why" may seem confrontational and might not foster a therapeutic relationship. It's important to respect the client's autonomy and decision-making process.
D. This response acknowledges the client's decision and demonstrates understanding and acceptance, which can help build trust and rapport between the nurse and the client.
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