A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
- Lower the side rails of the bed when the seizure begins.
- Measure the duration of the seizure.
- Restrain the client's arms and legs to prevent injury.
Insert an oral airway into the client's mouth.
Lower the side rails of the bed when the seizure begins.
Measure the duration of the seizure.
Restrain the client's arms and legs to prevent injury.
Insert an oral airway into the client's mouth.
The Correct Answer is B
Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them.
Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention.
Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The nurse should take the following actions when receiving a telephone prescription from a client's provider:
- Ask the provider to spell out the name of the medication: This is important to ensure accurate transcription of the medication name. Spelling out the name helps prevent errors due to similar-sounding medications or confusion with abbreviations.
- Request that the provider confirm the read-back of the prescription: This step ensures that the nurse and the provider are on the same page and that the prescription has been accurately transcribed. It allows for verification and correction if any discrepancies are identified.
- Record the date and time of the telephone prescription: Documenting the date and time of the telephone prescription is essential for tracking and reference purposes. It helps establish a clear timeline of events and ensures proper documentation of the medication order.
It is not necessary to withhold the medication until the provider signs the prescription, as telephone prescriptions are typically followed up with a written prescription or electronic verification.
Instructing another nurse to record the prescription in the medical record may not be necessary, as the nurse who received the telephone prescription is responsible for accurately documenting the order in the medical record. However, if necessary, the nurse can delegate the task of documentation to another qualified staff member under their supervision, ensuring accuracy and completeness.
Correct Answer is A
Explanation
A- "My partner will use condoms with spermicides": Using condoms with spermicides can increase the effectiveness of contraception by combining a barrier method with a chemical method to kill sperm.
B.Using two condoms simultaneously (also known as "double bagging") is not recommended because the friction between them can increase the chance of them tearing.
C- "I will be able to remove my contraceptive sponge immediately after intercourse": The contraceptive sponge is a barrier method that is inserted into the vagina before intercourse. It should be left in place for at least 6 hours after intercourse to ensure effectiveness. Removing it immediately after intercourse would decrease its contraceptive effectiveness.
D- "My partner and I will use petroleum jelly with latex condoms": Petroleum jelly, along with other oil-based lubricants, should not be used with latex condoms. Oil-based substances can degrade latex, making the condom more prone to breakage. Water-based lubricants are recommended for use with latex condoms to ensure their integrity and effectiveness.
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