A nurse is caring for a client who ingested a poison and is now having seizures.
Which of the following is the priority action the nurse should take?
Maintain the patency of the client's airway.
Identify the poison the client ingested.
Measure the client's blood pressure.
Position the client on her side.
The Correct Answer is A
Choice A rationale:
"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.
Choice B rationale:
"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.
Choice C rationale:
"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.
Choice D rationale:
"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .
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Related Questions
Correct Answer is ["A"]
Explanation
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
Correct Answer is C
Explanation
Choice A rationale:
Modified equivalents. This is not the correct answer. The abbreviation "mEq" stands for milliequivalents, not modified equivalents.
Choice B rationale:
Megaequivalents. This is not the correct answer. "Mega" is a prefix indicating a factor of one million. In the context of electrolytes and medications, milliequivalents (mEq) are the appropriate unit of measurement, not megaequivalents.
Choice C rationale:
Milliequivalents. This is the correct answer. Milliequivalents (mEq) are a measure of the chemical combining power of a substance. In medical contexts, mEq is often used to express the amount of electrolytes (such as potassium, sodium, calcium) in a solution or dosage form. It represents 1/1000th of an equivalent, which is the amount of a substance that can react with or replace one mole of hydrogen ions (H+) It is important for healthcare professionals to understand these units when dealing with medications and intravenous fluids, as incorrect administration can lead to serious health complications.
Choice D rationale:
Miniequivalents. This is not the correct answer. "Mini" is not a standard prefix used in the International System of Units (SI) The correct prefix for a thousandth of an equivalent is "milli," making milliequivalents the appropriate unit of measurement for substances like electrolytes.
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