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 D
Explanation
A. Inflating the catheter's balloon is not appropriate when resistance is encountered before reaching the bladder. It could cause trauma or injury.
B. Lowering the penis to a 45° angle may help facilitate catheter insertion initially, but if resistance is encountered, further interventions are needed.
C. Applying lidocaine gel to the urethra may help with discomfort during catheter insertion but will not address the issue of encountering resistance.
D. Twisting the catheter gently can help navigate any obstructions or curves in the urethra. This maneuver should be performed carefully to avoid causing trauma to the urethral mucosa.
Correct Answer is A,B,C,D,E
Explanation
Pouring 0.9% sodium chloride solution into the sterile basin provides the solution necessary for cleaning the inner cannula.
Unlocking and removing the inner cannula is the first step in the process of tracheostomy care.
Scrubbing the inside and outside of the inner cannula with a small brush helps remove secretions and debris.
Wiping the inside of the inner cannula with a folded pipe cleaner further cleans the inner surfaces.
Cleansing the stoma site with 0.9% sodium chloride solution completes the tracheostomy care procedure.
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