A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Provide oxygen.

Turn the client onto his side.

Provide privacy.

Lower the client to the floor.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.

Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.

Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.

Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.

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Correct Answer is C

Explanation

Choice A reason: A cholesterol level of 195 mg/dL is not an increased risk for atherosclerosis, because it is within the normal range of less than 200 mg/dL. Cholesterol is a type of fat that circulates in the blood and can contribute to plaque formation in the arteries.

Choice B reason: Elevated HDL levels are not an increased risk for atherosclerosis, because HDL stands for high-density lipoprotein, which is the "good" cholesterol that helps to remove excess cholesterol from the blood and prevent plaque formation in the arteries.

Choice C reason: Elevated LDL levels are an increased risk for atherosclerosis, because LDL stands for low-density lipoprotein, which is the "bad" cholesterol that can deposit in the arterial walls and cause plaque formation and narrowing of the arteries.

Choice D reason: A triglyceride level of 135 mg/dL is not an increased risk for atherosclerosis, because it is within the normal range of less than 150 mg/dL. Triglycerides are another type of fat that circulates in the blood and can contribute to plaque formation in the arteries.

A. Estimation of burn injury B. Respiratory rate C. Presence of bowel sounds D. Level of pain

Correct Answer is B

Explanation

Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.

Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

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A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Nursing Test Bank

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