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. While repositioning is important for comfort and preventing pressure ulcers, repositioning every 4 hours may not be sufficient, and it does not directly address the client's dyspnea.
B. Circulating air with a fan can help reduce the sensation of breathlessness and improve comfort for clients experiencing dyspnea. This non-invasive measure can be effective in relieving symptoms.
C. Placing the head of the bed flat is generally not recommended for clients with dyspnea, as it can worsen breathing difficulties. Elevating the head of the bed is usually more helpful.
D. Frequent oral care is important for maintaining comfort, especially in end-of-life care, but every 8 hours might not be sufficient. More frequent oral care is typically needed, and while important, this does not directly address dyspnea.
Correct Answer is D
Explanation
A. Napping during the day may disrupt nighttime sleep patterns by reducing sleep drive.
B. Watching television in bed can stimulate the brain and interfere with sleep due to the blue light emitted from screens.
C. Engaging in vigorous physical activity close to bedtime may increase alertness and make it harder to fall asleep.
D. Drinking a glass of milk before bedtime can promote sleep due to the presence of tryptophan, which aids in the production of serotonin and melatonin, neurotransmitters involved in sleep
regulation.
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