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 B
Explanation
A. Using overhead lighting can disrupt the client's sleep by increasing stimulation; instead, use minimal lighting during nighttime assessments.
B. Keeping the door to the client's room closed can help reduce noise and disturbances from the hallway, promoting a more conducive sleep environment.
C. Providing snug-fitting nightwear may not directly address the underlying causes of insomnia and might not be effective for all clients.
D. Administering diuretics in the evening may exacerbate nocturia and disrupt sleep patterns; instead, diuretics are typically given earlier in the day to minimize nighttime urination.
Correct Answer is A
Explanation
A. Using a 10-mL syringe filled with cleansing solution provides appropriate pressure for effective wound irrigation.
B. Drying the wound bed with gauze squares is not typically recommended as it may disrupt healing and cause trauma to the wound.
C. Cleansing the wound with cotton balls may leave fibers behind and is not the most effective method of wound irrigation.
D. Holding the syringe tip 2.5 cm (1 in) above the wound is incorrect; the tip should be inserted into the wound to facilitate thorough irrigation.
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