Exhibits

The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room.
Which 3 interventions should be performed first?

Place pillows around the bed rails to provide padding.

Watch the seizure activity and document the time and client movement.

Manually ventilate the client with a bag-valve mask (BVM).

Stop the IV fluids.

Increase the supplemental oxygen to 10 L/minute via nasal cannula.

Begin chest compressions.

Answer and Explanation

Correct Answer : B,C,E

A.   This is important to prevent injury but is not the priority at this time.
B.   This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C.   This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D.   This is not necessary at this point and may not be feasible during the emergency situation.
E.   While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F.   Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

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Correct Answer is C

Explanation

A. A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B. Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C. Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D. “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

A. Ask the client to rate her pain on a scale from 0 to 10. B. Teach the client to keep the leg elevated C. Treat with ice then apply an elastic bandage wrap. D. Check the leg for warmth and erythema.

Correct Answer is D

Explanation

A. While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B. Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C. Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D. The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.

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Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is D

Explanation

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Exhibits

The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room.
Which 3 interventions should be performed first?