A nurse is caring for a client who is receiving intravenous fluids. The nurse notes the client's skin around their peripheral IV site is taut and edematous. Which of the following complications is the client experiencing?

Rationale for Correct Choices:

• Turn the patient on their side: During a seizure, the first priority is to ensure the patient’s safety. Turning the client on their side helps prevent aspiration of saliva or vomit and keeps the airway clear, reducing the risk of choking or aspiration pneumonia.
• Loosen the client's gown: After ensuring safety and airway, the nurse should promote comfort and airflow by loosening restrictive clothing. This can help minimize risk of injury and ease breathing during or immediately after the seizure.

Rationale for Incorrect Choices:

• Note the time: While documenting the time of the seizure is important, the immediate action should focus on the patient’s airway and safety. After ensuring that the patient is safe, noting the time can be done to track the event for clinical purposes.
• Document the seizure event: Documentation is essential, but the first priority should be the safety of the patient. Once the patient is stable and their safety is ensured, documenting the seizure event can be done. This would follow airway management and patient safety.
• Reorienting the client: The immediate postictal period, the client may still be confused or disoriented due to the aftereffects of the seizure. The immediate priority should be airway management and comfort rather than reorientation, which can occur later.
• Administering anticonvulsant medications: If the seizure lasts for an extended period (over 5 minutes) or if seizures recur, anticonvulsant medications would be necessary. However, in this scenario, the seizure has already stopped. The first actions are to ensure airway safety, reposition the client, and provide comfort.

A. Leave resuscitation equipment and supplies at the bedside: This can be distressing for the family. Removing such equipment before the family views the body promotes a more peaceful environment.

B. Hold the client's eyelids closed until they remain shut: This is part of postmortem care to maintain a natural appearance. It shows respect and helps prepare the body before the family views it.

C. Apply identification tags to the client's extremities: While necessary, identification tagging is not a priority before the family views the body. It is typically done before transport to the morgue.

D. Keep the head of the bed flat: Elevating the head of the bed slightly helps prevent discoloration due to blood pooling and gives the body a more natural appearance. Keeping it flat is not ideal.