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 D
Explanation
A: Degenerative joint changes can affect mobility and overall health but do not directly contribute to aspiration pneumonia.
B: Decreased gastric secretions can affect digestion but are not a primary factor in the development of aspiration pneumonia.
C: A decreased sense of smell can affect appetite and food intake but does not directly lead to aspiration pneumonia.
D: A diminished cough reflex is a significant age-related change that can contribute to the development of aspiration pneumonia. The cough reflex helps clear the airway of food, liquid, and other foreign materials. When this reflex is diminished, the risk of aspiration and subsequent pneumonia increases.
Correct Answer is ["4.0"]
Explanation
Step 1: Determine the dosage required. 320 mg
Step 2: Determine the concentration of the suspension. 400 mg per 5 mL
Step 3: Calculate the volume needed. 320 mg ÷ 400 mg per 5 mL = 320 ÷ 400 × 5 = 0.8 × 5 = 4 mL
The nurse should administer 4.0 mL per dose.
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