A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

Apply restraints if the client is agitated.

Ambulate the client.

Position the client on their side.

Raise all of the side rails on the client's bed.

Answer and Explanation

The Correct Answer is C

A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.

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Correct Answer is A

Explanation

A. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}

Explanation

The nurse should prepare to administer naloxone and oxygen by face mask 10 L/min.

Rationale:

Naloxone is used to reverse opioid-induced respiratory depression, which is a potential risk during moderate sedation.
Oxygen by face mask 10 L/min is necessary to maintain adequate oxygenation during and after sedation, as respiratory depression can occur.

Acetaminophen is not used for immediate management of sedation-related complications.
An additional dose of fentanyl or propofol would deepen sedation, not manage its complications.
Propranolol is a beta-blocker that is not indicated in this situation.

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A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

Nursing Test Bank

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