A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?
Apply restraints to the client.
Administer an IV bolus of lorazepam.
Place the client in the prone position.
Insert a tongue blade into the client's mouth.
The Correct Answer is B
Choice A reason: Applying restraints to the client is not an appropriate action, as it can cause injury or suffocation to the client during a seizure. The nurse should protect the client from harm by removing any nearby objects and padding the side rails.
Choice B reason: Administering an IV bolus of lorazepam is an appropriate action, as lorazepam is an anticonvulsant drug that can stop or shorten the duration of a seizure by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain.
Choice C reason: Placing the client in the prone position is not an appropriate action, as it can obstruct the airway and cause respiratory distress or aspiration during a seizure. The nurse should place the client in the side-lying position to facilitate drainage of oral secretions and prevent tongue biting.
Choice D reason: Inserting a tongue blade into the client's mouth is not an appropriate action, as it can cause oral trauma or choking during a seizure. The nurse should never force anything into the client's mouth during a seizure and should allow them to breathe spontaneously.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: HbA1c or glycated hemoglobin is a measure of average blood glucose levels over the past 2 to 3 months. A lower HbA1c indicates better glycemic control and a lower risk of diabetes complications. The target HbA1c for most people with diabetes mellitus is less than 7%.
Choice B reason: HbA1c 12.5% is very high and indicates poor glycemic control and a high risk of diabetes complications, such as retinopathy, nephropathy, or neuropathy.
Choice C reason: Fasting blood glucose 100 mg/dL is within the normal range of 70 to 99 mg/dL and indicates normal glucose metabolism, but it does not reflect the long-term control of blood glucose levels over the past 3 months.
Choice D reason: Fasting blood glucose 70 mg/dL is at the lower end of the normal range and may indicate hypoglycemia or low blood glucose levels, which can cause symptoms such as sweating, trembling, hunger, or confusion.
Correct Answer is D
Explanation
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
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