A nurse is caring for a patient who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Place a pillow under the patient's head.

Loosen restrictive clothing.

Clear the area of hazards.

Position the patient in a side-lying position.

Answer and Explanation

The Correct Answer is D

A. Placing a pillow under the patient's head is inappropriate because it may obstruct the airway and does not prevent aspiration.

B. Loosening restrictive clothing can be helpful but is not the priority over airway protection.

C. Clearing the area of hazards is important to prevent injury, but airway protection takes precedence.

D. Positioning the patient in a side-lying position is the priority to maintain airway patency and reduce the risk of aspiration in case of vomiting.

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Correct Answer is A

Explanation

A. Correct. Moving objects prevents injury during a seizure.

B. Incorrect. The patient should be placed on their side to maintain airway patency.

C. Incorrect. Restraining the patient can cause injury.

D. Incorrect. Never insert anything into a seizing patient’s mouth, as it can obstruct the airway or break teeth.

A. 8:00am to 11:00am B. 2:00pm to 5:00pm C. 2:00am to 5:00am D. 10:00pm to 12:00am

Correct Answer is B

Explanation

A. 8:00 AM to 11:00 AM. – Incorrect. NPH insulin peaks in 6–14 hours, not within a few hours.

B. 2:00 PM to 5:00 PM. – Correct Answer. NPH insulin peaks around 6–14 hours, making this the most likely time for hypoglycemia.

C. 2:00 AM to 5:00 AM. – Incorrect. This would be the peak time for evening NPH insulin, not morning administration.

D. 10:00 PM to 12:00 AM. – Incorrect. NPH insulin does not peak this late when given in the morning.

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A nurse is caring for a patient who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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