A nurse is planning care for a client who has status epilepticus.
Which of the following interventions is the nurse's priority to include?
Administer phenytoin IV bolus to the client.
Administer diazepam intravenously to the client.
Provide the client oxygen at 6 L/min using a nasal cannula.
Turn the client to the lateral position during seizure activity.
The Correct Answer is B
The priority intervention for a nurse planning care for a client who has status epilepticus is to administer diazepam intravenously to the client.
Diazepam is a benzodiazepine medication that can help stop seizure activity and is often used as a first-line treatment for status epilepticus.
Choice A is incorrect because while phenytoin can be used to treat seizures, it is not typically used as a first-line treatment for status epilepticus.
Choice C is incorrect because while providing oxygen can be an important intervention for clients experiencing seizures, it is not the priority intervention.
Choice D is incorrect because while turning the client to the lateral position during seizure activity can help prevent aspiration, it is not the priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should ensure that the client is discharged with antithrombotic pharmacologic therapy.
Antithrombotic medications help prevent blood clots from forming and can reduce the risk of another ischemic stroke.
Choice B is wrong because diuretics are used to treat fluid retention and high blood pressure and are not typically used for stroke prevention.
Choice C is wrong because anticonvulsants are used to prevent seizures and are not typically used for stroke prevention.
Choice D is wrong because opioid analgesics are used to treat pain and are not typically used for stroke prevention.
Correct Answer is C
Explanation
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
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