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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Monitoring cardiac rhythm is not specifically necessary for ethambutol therapy.
B. Urine output is not a primary concern related to ethambutol use.
C. Visual acuity should be monitored because ethambutol can cause optic neuritis, which may lead to vision changes and requires regular assessment.
D. Skin color is not a specific concern with ethambutol therapy; monitoring for visual changes is more pertinent.

A. Arteriovenous fistula B. Implanted infusion port C. Short peripheral catheter D. Peripherally inserted central catheter

Correct Answer is D

Explanation

A. An arteriovenous fistula is used for dialysis, not for long-term antibiotic therapy.
B. An implanted infusion port is suitable for long-term therapy but is typically used for medications that require infusions over weeks or months rather than prolonged IV therapy.
C. A short peripheral catheter is not appropriate for extended therapy due to the risk of thrombophlebitis and infiltration.
D. A peripherally inserted central catheter (PICC) is appropriate for long-term intravenous antibiotic therapy as it provides reliable access and reduces the risk of complications associated with extended peripheral catheter use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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