A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?
Check the patency of the client's airway.
Determine the poison that was ingested.
Position the client side-lying
Identify the amount of poison that was ingested.
The Correct Answer is A
A. Checking the patency of the client's airway is the priority action because maintaining a clear airway is crucial during a seizure to ensure adequate oxygenation and prevent aspiration.
B. Determining the poison is important but not the immediate priority during a seizure.
C. Positioning the client side-lying is important to prevent aspiration, but the first action should be to ensure the airway is clear.
D. Identifying the amount of poison ingested is important for treatment but not the immediate priority during a seizure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.
Correct Answer is B
Explanation
A. Gelatin is typically allowed on a clear liquid diet because it melts into a clear liquid.
B. Yogurt is not typically included on a clear liquid diet because it is not a clear liquid; it is a semi-solid food.
C. Popsicles are usually allowed on a clear liquid diet as they melt into a liquid form.
D. Broth is a clear liquid and is therefore appropriate for a clear liquid diet.
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