A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side.
Check the client's motor strength.
Document the time the seizure began.
Loosen the clothing around the client's waist.
The Correct Answer is A
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
To calculate the gt/min, the nurse should use the following formula:
gt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gt/min = (150 mL/hr x 20 gt/mL) / 60
gt/min = 3000 gt/hr / 60 gt/min = 50 gt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gt/min.
Correct Answer is ["24"]
Explanation
To calculate the infusion rate, use the formula:
(rate in mL/hr) = (desired dose in units/hr) / (available dose in units/mL)
In this case, the desired dose is 1,200 units/hr and the available dose is 25,000 units / 500 mL = 50 units/mL. Therefore,
(rate in mL/hr) = (1,200 units/hr) / (50 units/mL) = 24 mL/hr
Round the answer to the nearest tenth/whole number and use a leading zero if it applies. Do not use a trailing zero because it could be misread as a decimal point. Therefore, the nurse should set the IV pump to deliver 24 mL/hr.
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