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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Ensure that the negative air pressure is active for the client’s room.": Negative air pressure is used for airborne precautions, such as in the case of tuberculosis or other airborne infections. MRSA is primarily spread through direct contact, not airborne transmission, so negative air pressure is not necessary in this situation.
B) "Place the client in a room with a high-efficiency particulate air (HEPA) filter.": A HEPA filter is used for airborne precautions to filter out airborne particles like those found in diseases such as tuberculosis or measles. Since MRSA is transmitted through direct contact and not airborne particles, placing the client in a room with a HEPA filter is not necessary.
C) "Have the client wear a mask when they are out of their room.": MRSA is typically spread by direct contact with infected wounds, bodily fluids, or contaminated surfaces. It is not transmitted via respiratory droplets, so there is no need for the client to wear a mask when they leave their room. The focus should be on contact precautions rather than respiratory precautions.
D) "Don gloves prior to assisting the client with brushing their teeth.": MRSA is a contact-borne infection, so it is essential to use proper personal protective equipment, such as gloves, when coming into direct contact with the client or any of their bodily fluids or contaminated items (such as toothbrushes). Donning gloves prior to assisting with brushing their teeth ensures that the nurse avoids direct contact with potential sources of infection. This is an important measure in preventing the spread of MRSA.
Correct Answer is B
Explanation
A) Beneficence:
Beneficence refers to the ethical principle of doing good and acting in the best interest of the client. While providing accurate information about the adverse effects of medications contributes to beneficence by ensuring the client’s safety, the specific focus here is on truthfulness in communication, which is more closely aligned with veracity.
B) Veracity:
Veracity is the ethical principle of truthfulness. In this scenario, the nurse is providing honest and accurate information about the medications, including their potential adverse effects. This aligns directly with the principle of veracity, which emphasizes the importance of being truthful and transparent in communication with clients, especially regarding their care and treatment.
C) Justice:
Justice refers to the ethical principle of fairness, ensuring that clients are treated equitably and that their rights are upheld. While the nurse may be demonstrating fairness in the care process, the focus in this scenario is on the truthfulness of the information provided, which is better aligned with the concept of veracity.
D) Autonomy:
Autonomy refers to respecting the client's right to make their own decisions regarding their care. While providing truthful information about medications supports the client’s ability to make informed decisions, the primary ethical principle being demonstrated by the nurse in this scenario is veracity, as the nurse is specifically focused on being truthful with the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.