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 D

Explanation

A. Applying petroleum jelly to the client's lips can lead to aspiration if the client is unable to swallow properly. It is not recommended as a routine practice for oral care.

B. A stiff toothbrush can cause gum damage or discomfort. A soft toothbrush is preferred for oral care, especially for clients who may have sensitive or fragile gums.

C. Using the thumb and index finger to keep the client's mouth open is not safe or effective. It can cause discomfort or injury. Using appropriate tools, like a mouth prop or suction if necessary, is recommended.

D. Turning the client on their side before starting oral care is the correct action. This position helps prevent aspiration of secretions or water during oral care, reducing the risk of choking or aspiration pneumonia.

Correct Answer is ["1.5"]

Explanation

- Identify the prescribed dose: The prescribed dose is 150 mg.
- Identify the strength available: The strength available is 100 mg per tablet.
- Calculate the number of tablets: Divide the prescribed dose by the strength available per tablet.
= 150/100= 1.5 tablets

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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

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["1.5"]

Explanation

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