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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. A blood glucose reading of 70 mg/dL is low but stable, and the client has already received treatment.
B. Pulling out a peripheral IV catheter is concerning but not immediately life-threatening.
C. New onset of indigestion in a client admitted for chest pain could indicate a cardiac event and requires immediate assessment.
D. A temperature of 38.9°C (102°F) in a client with pneumonia needs monitoring but is not as urgent as potential cardiac issues.

A. Positions the wrapped package on the bedside table so the outer flap is away from her. B. Holds gauze packages 15 cm (6 in) above the sterile field. C. Holds a bottle of solution with the label away from the palm of the hand. D. Wears sterile gloves when moving sterile items on the sterile field.

Correct Answer is C

Explanation

A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.

B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.

C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.

D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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