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?
Check the client’s motor strength.
Turn the client’s head to the side.
Document the time the seizure began.
Loosen the clothing around the client’s waist.
The Correct Answer is B
A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.
B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.
C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.
D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: A BUN level of 165 mg/dL is extremely high and suggests severe dehydration or possible renal failure. This level is far above the normal range and indicates a critical condition.
B: A BUN level of 35 mg/dL is elevated and consistent with dehydration. Dehydration causes the kidneys to reabsorb more water, leading to higher concentrations of urea in the blood.
C: A BUN level of 10 mg/dL is within the normal range and does not indicate dehydration. This level suggests normal kidney function and hydration status.
D: A BUN level of 31 mg/dL is elevated and suggests dehydration. While not as high as 165 mg/dL, it still indicates that the patient is dehydrated and requires intervention.
Correct Answer is C
Explanation
A: 20 mg is incorrect and represents a significant overdose. It is not an appropriate transcription for two tenths of a milligram.
B: 0.20 mg is not the best practice because it can be misread as 20 mg if the decimal point is missed. Leading zeros should be used without trailing zeros to prevent errors.
C: 0.2 mg is the correct transcription. It clearly represents two tenths of a milligram and minimizes the risk of misinterpretation.
D: 2.0 mg is incorrect and represents a tenfold overdose. It is not an appropriate transcription for two tenths of a milligram.
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