A nurse on a medical-surgical unit is checking the bowel sounds of a client who has epilepsy.
The client begins to experience a tonic-clonic seizure.
Identify the sequence of steps the nurse should follow.
(Move the steps into the box on the right, placing them in the selected order of performance.
Use all the steps.).

Reorient and reassure the client.

Remain with the client and call for help.

Check the client for injuries.

Place the client in the lateral position.

Answer and Explanation

The Correct Answer is B

Step 1 is B. Remain with the client and call for help. This ensures the client’s safety and gets additional assistance. Step 2 is D. Place the client in the lateral position. This prevents aspiration if the client vomits. Step 3 is C. Check the client for injuries. After the seizure has ended, the nurse should assess for any injuries that may have occurred during the seizure. Step 4 is A. Reorient and reassure the client. After a seizure, the client may be confused and scared. Reorienting and reassuring the client can help them recover. So, the correct sequence is B, D, C,

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

Blistering around the insertion site is not a common sign of phlebitis. It could indicate a more severe complication like extravasation or infiltration.

Choice B rationale:

Streak formation along the vein is a classic sign of phlebitis. It indicates inflammation and possible infection.

Choice C rationale:

Erythema at the insertion site is another common sign of phlebitis. It indicates inflammation.

Choice D rationale:

Warmth at the insertion site is also a common sign of phlebitis. It is caused by increased blood flow to the area due to inflammation. So, the correct answers are B, C, and D.

Correct Answer is ["31"]

Explanation

Step 1 is to determine the total volume to be infused in minutes. This is done by multiplying the total volume by the drop factor: (1000 mL ÷ 480 min) × 15 gtt/mL = 31.25 gtt/min.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client's IV site.The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.).

Correct Answer is ["B","C","D"]

Explanation

Correct Answer is ["31"]

Explanation

A nurse is reinforcing teaching with a client who is taking benztropine to treat Parkinson's disease.The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?.

A nurse is preparing to administer olanzapine 7.5 mg PO to a client who has schizophrenia. Available is olanzapine 2.5 mg tablets. How many tablets should the nurse plan to administer? (Round to the nearest whole number. Use a leading zero if it applies.

A nurse is modifying the diet of a client who has Parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate from the client's diet?.

A nurse is preparing to administer valproic acid 500 mg PO. Available is valproic acid oral solution 250 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.)

A nurse is reinforcing teaching with a client who has a prescription for lithium carbonate to treat bipolar disorder.Which of the following instructions should the nurse include?.

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A nurse is preparing to administer fluoxetine 30 mg PO for a client who has depression and cannot swallow capsules. Available is fluoxetine 20 mg/5 mL oral solution. How many mL should the nurse plan to administer? (Round to the nearest tenth. Use a leading zero if it applies.)

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen.Which of the following instructions should the nurse include?.