A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Insert an oral airway into the client’s mouth

Measure the duration of the seizure.

Lower the side rails of the bed when the seizure begins.

Restrain the client's arms and legs to prevent injury.

Answer and Explanation

The Correct Answer is D

A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.

B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.

C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.

D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.

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Correct Answer is C

Explanation

A) "I should expect my periods to resume in 1 month.": This statement suggests a misunderstanding of the procedure. After a vaginal hysterectomy, periods will not resume because the uterus is removed. If a client expresses such expectations, it may indicate a lack of understanding about the procedure's outcomes and risks, meaning informed consent may not have been adequately given.

B) "I will have a large scar on my stomach after this procedure.": A vaginal hysterectomy is typically performed through the vaginal canal, not requiring an abdominal incision. Therefore, this statement reflects a misunderstanding of the procedure's approach, and would indicate that the client has not been fully informed about the surgical method.

C) "I am thankful I am done having children.": This statement indicates that the client has understood one of the key reasons for having a vaginal hysterectomy. The procedure typically results in the inability to conceive children, which is an important consideration for informed consent. It shows the client is aware of the consequences and is making an informed decision.

D) "I will no longer need regular gynecological examination.": This statement reflects a misunderstanding. Even after a hysterectomy, it’s important for clients to continue routine gynecological exams, as they may still need to monitor other aspects of their reproductive health, including the vagina and ovaries (if retained). It indicates that the client may not have been fully informed about post-operative care requirements.

A. *Restrict your daily fluid intake." B. *Take a daily potassium supplement." C. *Discontinue this medication if this occurs again." D. "Sit back down for a few minutes when this occurs."

Correct Answer is D

Explanation

A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.

B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.

C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.

D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.

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A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is verifying informed consent for a client who is preoperative for vaginal hysterectomy. Which of the following statements should thenurse identify as an indication that the client has given informed consent?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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