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. Urinary output is important but secondary to respiratory concerns in this postoperative context.
B. Arterial blood gases provide valuable information but are less immediate compared to issues directly affecting lung function.
C. Chest tube drainage is critical to monitor for complications such as pneumothorax or hemothorax, which are significant concerns post-thoracotomy and lobectomy.
D. Pain level is important for patient comfort but does not have the immediate impact on recovery compared to chest tube drainage.

A. Vitamin C B. Oxalates C. Fiber D. Vitamin A

Correct Answer is A

Explanation

A. Vitamin C enhances the absorption of non-heme iron from plant-based sources by converting iron to a more absorbable form. Including vitamin C-rich foods with iron-rich meals can improve iron uptake.
B. Oxalates, found in foods like spinach and rhubarb, can inhibit iron absorption by binding to iron and reducing its availability.
C. Fiber, while beneficial for digestive health, does not enhance iron absorption and can, in some cases, inhibit it by binding to minerals.
D. Vitamin A does not have a direct role in the absorption of iron, though it is essential for overall health.

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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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Explanation

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