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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale for A:

A small hematoma at the catheter insertion site is common after cardiac catheterization due to the puncture of blood vessels. The nurse should inform the client that this may occur but reassure them that it typically resolves on its own.

Rationale for B:

The dressing usually remains intact for 24 to 48 hours post-procedure to prevent infection and promote healing. The client should be instructed to keep the dressing clean and dry until the healthcare provider gives specific instructions.

Rationale for C: Clients are usually advised to avoid strenuous activities and exercise for several days after the procedure, not to resume regular exercise the next day.

Rationale for D: Pain medication may be necessary to manage discomfort post-procedure, and the nurse should encourage the client to take pain relief as needed.

A. Ask the client if any other foods cause such a reaction. B. Notify the provider of the client's allergy. C. Notify the dietary department of the client's allergy. D. Atach a wrist band indicating the client's allergy.

Correct Answer is B

Explanation

The priority nursing action is to notify the provider of the client's allergy because shellfish allergy may indicate an allergy to iodine, which is commonly used as a contrast dye in cardiac catheterization. This could cause a severe allergic reaction or anaphylaxis during the procedure, which could be life-threatening. The provider may need to order a diﬀerent type of contrast dye or premedicate the client with antihistamines or steroids to prevent an allergic reaction.

a. Ask the client if any other foods cause such a reaction is wrong because it is not the priority action and it does not address the potential risk of iodine allergy.

c. Notify the dietary department of the client's allergy is wrong because it is not relevant to the cardiac catheterization and it does not prevent an allergic reaction during the procedure.

d. Atach a wrist band indicating the client's allergy is wrong because it is not sufficient to alert the provider or the catheterization team of the client's allergy and it does not prevent an allergic reaction during the procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

Correct Answer is A

Explanation

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?

Correct Answer is B

Explanation

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