A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Place a pillow under the child's head.

Clear the area of hazards.

Position the child side-lying

Loosen restrictive clothing

Answer and Explanation

The Correct Answer is C

A. Place a pillow under the child's head.

Explanation: While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.

B. Clear the area of hazards.

Explanation: Correct Choice. Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.

C. Position the child side-lying.

Explanation: Correct Choice. Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions.

D. Loosen restrictive clothing.

Explanation: While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.

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Correct Answer is ["2"]

Explanation

The nurse should administer 2 tablets.

Here's the calculation:

650 mg / 325 mg per tablet = 2 tablets

Since the nurse should administer a whole number of tablets, the answer is 2 tablets.

A. Assume you made a mistake and report out the same head circumference as the before B. Take Vital Signs C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Correct Answer is C

Explanation

A. Assume you made a mistake and report out the same head circumference as before.

Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.

Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.

B. Take Vital Signs.

Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.

Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.

C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.

Correct Explanation: This is the best next step.

Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.

D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.

Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.

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A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer aspirin 650 mg PO every 12 hr. The amount available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?

Correct Answer is C

Explanation

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