A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen?

Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.

i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.

ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.

Rationale for incorrect answers:

remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.

reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.

administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.

A. Store the oxygen cylinder wrench with the oxygen tank.: The wrench is necessary to open the oxygen tank in an emergency or when changing tanks. Keeping it with the tank ensures it is immediately available for the client or caregiver.

B. Take steroid medication in the morning.: Prednisone (a corticosteroid) can cause insomnia and restlessness. Taking it in the morning aligns with the body's natural circadian rhythm of cortisol production and helps prevent sleep disturbances.

C. Decrease the steroid dose each day.: The prescription states "40 mg PO daily for 5 days." The nurse should instruct the client to take the full dose as prescribed. While steroids are often tapered, the client should not self-taper unless specifically directed by the provider's prescription.

D. Take antibiotic medication with or without food.: Cephalexin can be taken without regard to meals. However, if the medication causes GI upset, taking it with food can help mitigate nausea.

E. Adjust the oxygen flow rate as needed to ease breathing.: Oxygen is considered a medication. The client must maintain the prescribed flow rate (3 L/min) and should never adjust it without a provider's order, as excessive oxygen can be harmful to some patients.

F. Ensure the oxygen delivery system is at least 8 feet from any heat source.: Oxygen supports combustion. To prevent fires, tanks and concentrators must be kept away from open flames, space heaters, candles, or gas stoves. Standard safety guidelines usually recommend 5 to 10 feet (8 feet is a safe middle ground).

G. Take antibiotics for 10 days.: The prescription specifically states "every 6 hr for 5 days." Taking medications for longer than prescribed is incorrect instruction.