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?
Document the time the seizure began.
Turn the client's head to the side.
Loosen the clothing around the client's waist.
Check the client's motor strength.
The Correct Answer is B
A. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.
B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.
C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.
D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Although auscultating breath sounds is important, it is not the immediate priority. The client’s symptoms suggest a possible allergic reaction or anaphylaxis.
B. Elevating the head of the bed is important for comfort but is not the first action in the event of a suspected allergic reaction.
C. Stopping the infusion is the first critical step to prevent further exposure to the allergen and reduce the risk of severe reactions.
D. Calling the provider is important but should occur after ensuring the immediate safety of the client by stopping the infusion.
Correct Answer is B
Explanation
A. A JP drain is not used for medication administration; its purpose is to remove fluid from the wound area.
B. The primary purpose of a JP drain is to prevent fluid from accumulating in the wound, which helps reduce the risk of infection and promotes healing by allowing continuous drainage of postoperative fluids.
C. While a JP drain helps manage fluid accumulation, it does not eliminate the need for wound irrigations if prescribed as part of the care plan.
D. A JP drain helps manage excess fluid but is not specifically designed to limit bleeding from the surgical site. Bleeding control is generally managed through other measures and monitoring.
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