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","D"]

Explanation

A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.

A. Take the medication in the morning to prevent insomnia. B. Drink 2 to 3 L of water per day while on the medication. C. Expect to have a fever for the first days of therapy. D. Administer the medication with an NSAID to enhance effectiveness.

Correct Answer is B

Explanation

A. Methotrexate is not typically associated with insomnia, and the timing of administration should be according to the provider's instructions.
B. Drinking 2 to 3 L of water per day helps prevent kidney damage and reduces the risk of side effects such as methotrexate toxicity.
C. Fever is not a common expected side effect of methotrexate and should be reported to the provider.
D. Combining methotrexate with NSAIDs can increase the risk of toxicity; this should only be done under direct medical supervision.

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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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Explanation

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Correct Answer is B

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