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. Insert an oral airway into the client’s mouth: Attempting to insert any object into the mouth during a seizure risks airway obstruction, dental injury, or aspiration of oral secretions or broken teeth. The jaw is typically clenched, making insertion unsafe and impractical.

B. Measure the duration of the seizure: While timing the seizure is important for documentation and determining if status epilepticus occurs, it should not take precedence over immediate physical safety measures. Restraint to prevent injury must occur first.

C. Lower the side rails of the bed when the seizure begins: Lowering the side rails increases the risk of the client falling from the bed. Instead, the bed rails should remain raised and padded (if possible) to create a contained, safe environment.

D. Restrain the client's arms and legs to prevent injury: Gentle but firm restraint of the extremities reduces the risk of the client striking themselves against hard surfaces (e.g., bed rails, walls) or experiencing dislocations, fractures, or self-inflicted trauma. Restraint should be applied cautiously to avoid excessive force, but it is necessary to maintain physical control during the seizure’s intense muscular contractions.

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Free Nursing Study Resources

Correct Answer is ["30"]

Explanation

To calculate the drip rate, follow these steps:

The client needs to receive 120 mL of lactated Ringer's over 1 hour (60 minutes).
The IV tubing has a drip factor of 15 drops per mL (15 gtt/mL).
Multiply the total volume (120 mL) by the drip factor (15 gtt/mL), which gives 1,800 drops.
Divide this by the total time in minutes (60 minutes).

1,800 drops ÷ 60 minutes = 30 drops per minute (30 gtt/min)

Final Answer:

30 gtt/min

A. Orange juice B. Baked chicken breast C. Sweet potato D. Cantaloupe

Correct Answer is B

Explanation

A) Orange juice:
Orange juice is high in potassium, with one cup containing a significant amount of the nutrient. For clients who need to limit their potassium intake due to an electrolyte imbalance (such as in kidney disease or hyperkalemia), orange juice should be avoided or consumed in limited amounts.

B) Baked chicken breast:
Baked chicken breast is the lowest in potassium among the options provided. While chicken does contain some potassium, it is relatively low compared to fruits and vegetables. This makes it a better choice for clients needing to limit their potassium intake. Lean meats like chicken are often recommended for clients on a restricted potassium diet.

C) Sweet potato:
Sweet potatoes are very high in potassium, especially when compared to many other vegetables. A serving of sweet potato can contain a large amount of potassium, making it unsuitable for clients who need to manage their potassium levels.

D) Cantaloupe:
Cantaloupe is also high in potassium. A single serving can provide a substantial amount of potassium, which can be problematic for clients with electrolyte imbalances who need to limit their potassium intake.

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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

Correct Answer is ["30"]

Explanation

Final Answer:

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

Correct Answer is B

Explanation

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