The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

Ensure oral suction is available.

Provide frequent mouth care.

Keep the room at a comfortable temperature.

Maintain the client in a semi-Fowler's position.

Answer and Explanation

The Correct Answer is A

A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.

B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.

C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.

D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Methotrexate is commonly used in the treatment of rheumatoid arthritis (RA) to slow the progression of the disease by suppressing the immune system's response that causes inflammation. Aspirin may be used concurrently to provide symptomatic relief from pain and inflammation associated with RA.
B. While methotrexate may have side effects, its primary indication in RA treatment is to slow disease progression rather than to mitigate aspirin side effects.
C. Methotrexate and aspirin typically work through different mechanisms of action and are not typically used together to enhance each other's effectiveness.
D. Methotrexate and aspirin have different side effect profiles, but the primary reason for adding methotrexate is to slow the progression of RA rather than to replace aspirin due to side effects.

A. Internal bleeding. B. Right-sided heart failure. C. Cardiac tamponade. D. Left ventricular dysfunction.

Correct Answer is B

Explanation

A. Internal bleeding may present with symptoms such as hypotension, tachycardia, and signs of blood loss, but it typically does not cause pitting edema or jugular venous distention.

B. Right-sided heart failure can cause systemic venous congestion, leading to pitting edema of the lower extremities and jugular venous distention due to increased central venous pressure.

C. Cardiac tamponade presents with Beck's triad (hypotension, distended neck veins, muffled heart sounds) and is typically more acute in onset compared to the gradual development of symptoms seen in right-sided heart failure.

D. Left ventricular dysfunction primarily causes symptoms of pulmonary congestion, such as dyspnea, orthopnea, and crackles, rather than pitting edema and jugular venous distention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?