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 D

Explanation

A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.

B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.

C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.

D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.

A. "Draw up the insulin lispro and insulin glargine in separate syringes. B. "Take an extra dose of insulin lispro prior to aerobic exercise." C. ‘’Expect insulin glargine to be cloudy." D. "Anticipate that the insulin glargine will peak in 3 hours."

Correct Answer is A

Explanation

A) "Draw up the insulin lispro and insulin glargine in separate syringes.":
Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should be administered separately, as they have different properties and mechanisms of action. Mixing them in one syringe can affect their effectiveness and may cause inaccurate dosing. Therefore, the nurse should instruct the client to draw up each insulin in a separate syringe to ensure proper administration and action of both insulins.

B) "Take an extra dose of insulin lispro prior to aerobic exercise.":
Taking an extra dose of insulin lispro before exercise is not recommended unless directed by a healthcare provider. Exercise can lower blood glucose levels, and additional insulin may increase the risk of hypoglycemia. Instead, clients with diabetes are typically advised to monitor their blood glucose levels before and after exercise and adjust their insulin dose or carbohydrate intake accordingly, under the guidance of their healthcare provider.

C) "Expect insulin glargine to be cloudy.":
Insulin glargine is a clear, long-acting insulin. It should not be cloudy. If the insulin appears cloudy, it may be a sign that the insulin has been improperly stored or is no longer effective. The nurse should educate the client to inspect the insulin for cloudiness or particles and to discard any insulin that appears abnormal.

D) "Anticipate that the insulin glargine will peak in 3 hours.":
Insulin glargine is a long-acting insulin that does not have a pronounced peak. It provides a steady release of insulin over 24 hours and helps to maintain baseline insulin levels. It is not meant to peak like rapid-acting or short-acting insulins. Therefore, this instruction is incorrect, as insulin glargine does not follow the same peak-action pattern as other insulins.

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