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.

None

Answer and Explanation

The Correct Answer is B

A. Attempting to force an object into the oral cavity during muscle contraction causes dental trauma or jaw fractures. It significantly increases the risk of aspiration if the object breaks or triggers a gag reflex. Modern clinical guidelines strictly prohibit the insertion of any device into the mouth during active convulsions. Airway patency is maintained by placing the client in a lateral position.

B. Tracking the exact duration of the ictal phase is a critical nursing responsibility for clinical assessment. This data determines the necessity for emergency benzodiazepines if the event lasts longer than 5 minutes. Precise timing helps differentiate between a self-limiting seizure and dangerous status epilepticus. The nurse must record the start and end times to guide medical intervention.

C. Lowering the side rails during a seizure increases the risk of the client falling from the height of the bed. Standard seizure precautions require that side rails remain raised and should be padded to prevent blunt force trauma. Ensuring the patient stays within the safe boundaries of the bed is a primary safety goal.

D. Physical restraints can cause severe musculoskeletal injuries such as fractures or dislocations during the forceful involuntary movements of the clonic phase. Restricting the extremities creates unnecessary resistance against powerful muscle contractions. The nurse should clear the immediate area of hard objects rather than holding the client down.

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Correct Answer is C

Explanation

A) Decreased hemoglobin level: A decreased hemoglobin level is not an expected or desirable outcome of taking furosemide. While furosemide can cause fluid loss, it does not directly affect red blood cell production or hemoglobin levels. A decrease in hemoglobin could indicate anemia or another underlying issue, which should be addressed separately.

B) Increased weight of 0.91 kg (2 lb): An increase in weight, especially in a client with heart failure, could indicate fluid retention rather than effective diuresis. Furosemide is a diuretic that helps reduce fluid buildup, so an increase in weight would typically suggest that the medication is not effectively managing fluid overload, which is a key issue in heart failure.

C) Increased urinary output: An increase in urinary output is a clear indicator that furosemide is working effectively. Furosemide is a loop diuretic, which promotes the excretion of sodium and water, leading to increased urine output. This helps reduce fluid volume in the body, which is beneficial for a client with heart failure.

D) Decreased BUN level: While furosemide can affect kidney function, a decrease in blood urea nitrogen (BUN) level is not a direct indicator of the medication’s effectiveness. BUN can be influenced by various factors such as hydration status, kidney function, and protein intake. A decreased BUN level does not directly correlate with furosemide's effectiveness in treating heart failure.

A. Two diarrhea stools in the last day B. Chemotherapy treatments C. Clear rhinorrhea D. Medications for a cardiac anomaly

Correct Answer is B

Explanation

A) Two diarrhea stools in the last day: Diarrhea, especially if it is mild and without other severe symptoms, is not a contraindication for receiving a varicella vaccine. The child may still be able to receive the immunization if they are otherwise well. However, if the diarrhea is accompanied by fever, vomiting, or other signs of illness, the vaccine may be delayed.

B) Chemotherapy treatments: Chemotherapy treatments are a contraindication for the varicella vaccine. Chemotherapy can suppress the immune system, making the child more vulnerable to infections, including the risk of contracting varicella from the live vaccine. Immunocompromised patients should not receive live vaccines unless approved by their healthcare provider.

C) Clear rhinorrhea: Clear rhinorrhea, or a runny nose, typically indicates a mild upper respiratory condition like a cold. This is not a contraindication for receiving the varicella vaccine unless other symptoms are more severe or the child has a fever or signs of a more serious illness.

D) Medications for a cardiac anomaly: Medications for a cardiac anomaly do not generally interfere with the safety of the varicella vaccine. These medications may require careful monitoring for other reasons, but they are not contraindications to receiving the immunization, as long as the child is not immunocompromised from other causes

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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