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 A
Explanation
The nurse should instruct the client to adjust the thermostat so that the environment is warm because cold temperatures can cause vasoconstriction and worsen the symptoms of PAD, such as pain, numbness, and poor wound healing. The client should also avoid exposure to cold weather and wear warm clothing.
- Apply a heating pad on a low setting to help relieve leg pain is wrong because it can cause burns, vasodilation, and increased blood flow to the legs, which can increase the risk of bleeding and edema in PAD.
- Wear antiembolic stockings during the day is wrong because they can impair arterial circulation and cause ischemia and tissue damage in PAD. Antiembolic stockings are used to prevent venous thromboembolism, not arterial disease.
Rest with the legs above heart level is wrong because it can decrease arterial blood flow to the legs and worsen ischemia and pain in PAD. The client should rest with the legs at or below heart level to promote arterial circulation.
Correct Answer is ["1 tablet"]
Explanation
To calculate the number of tablets, divide the total dose by the dose per tablet. In this case, the total dose is 1.5 mg / 3 = 0.5 mg and the dose per tablet is 0.5 mg. Therefore,
(number of tablets) = (0.5 mg) / (0.5 mg) = 1 tablet
Round the answer to the nearest tenth 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 administer 1 tablet per dose.
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