A nurse is caring for a school-age child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a folded blanket under the child's head.

Put a tongue blade between the child's teeth.

Administer magnesium sulfate IM to the child.

Prevent movement of the child's extremities.

Answer and Explanation

The Correct Answer is A

A. Placing a folded blanket or any soft object under the child's head helps to protect the head from injury during the seizure. Ensuring safety is a priority during a seizure.
B. Putting a tongue blade or any object between the child's teeth can cause injury to the child. It is no longer recommended to place anything in the mouth during a seizure.
C. Magnesium sulfate is not indicated for treating tonic-clonic seizures. The focus should be on maintaining safety and monitoring the seizure.
D. Preventing movement of the child's extremities can cause injury. Instead, the nurse should protect the child from harm and ensure the environment is safe.

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Correct Answer is C

Explanation

A. Residual fluid should not be discarded unless instructed by a healthcare provider, as it provides important information about gastric emptying and tolerance to previous feedings.
B. Formula should be brought to room temperature before administration to avoid causing discomfort or gastric irritation. Cold formula can cause cramps and slow gastric motility.
C. Elevating the head of the bed to a 45-degree angle helps prevent aspiration during feeding and promotes proper digestion. This position is critical for patient safety.
D. The feeding rate should be individualized based on the child's tolerance and prescribed regimen, and 30 mL/min is typically too fast for a preschooler, increasing the risk of aspiration or intolerance.

A. An increase in the child's potassium level B. A decrease in the child's edema C. An increase in the child's respiratory rate D. A decrease in the child's appetite

Correct Answer is B

Explanation

A. An increase in potassium levels is not directly related to the effectiveness of furosemide, which is a diuretic and can actually cause hypokalemia.
B. A decrease in edema indicates that the diuretic is effectively removing excess fluid from the body, which is a desired effect of furosemide in treating heart failure.
C. An increase in respiratory rate could indicate worsening heart failure or fluid overload, not the effectiveness of the medication.
D. A decrease in appetite is not a specific indication of the effectiveness of furosemide.

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