The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Maintain a patent airway

Place an intravenous catheter (IV)

Administer diazepam, per order

Insert a nasogastric tube (NG)

Answer and Explanation

The Correct Answer is A

Choice A rationale
Maintaining a patent airway is the highest priority when providing care for a patient in status epilepticus. Status epilepticus is a medical emergency characterized by prolonged or recurrent seizures. It can lead to severe complications, including respiratory distress and hypoxia.
Therefore, ensuring a patent airway is crucial to prevent hypoxia and further brain damage. This involves positioning the patient to prevent aspiration, potentially suctioning the airway, and providing supplemental oxygen as needed.
Choice B rationale
While placing an intravenous catheter (IV) is an important intervention, it is not the highest priority. An IV allows for the administration of medications and fluids, which are necessary in the management of status epilepticus. However, it is secondary to maintaining a patent airway.
Choice C rationale
Administering diazepam or other antiepileptic drugs is a key intervention in managing status epilepticus. These medications help to stop the seizures. However, medication administration should only occur after a patent airway has been established.
Choice D rationale
Inserting a nasogastric tube (NG) may be necessary in some cases to protect the airway or for administering medications or nutrition. However, this is not the highest priority intervention. The first step in managing status epilepticus is always to ensure a patent airway.

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Free Nursing Study Resources

Correct Answer is ["4 "]

Explanation

The nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL.

Step 1 is: Calculate the dose in mL using the formula: (Desired dose ÷ Available dose) × Volume.

Step 2 is: Substitute the given values into the formula: (40 mg ÷ 10 mg) × 1 mL = 4 mL. The nurse should administer 4 mL per dose.

A. Assessing the patient’s ability to follow complex commands B. Assessing the patient’s judgment C. Assessing the patient’s verbal response D. Assessing the patient’s response to pain

Correct Answer is D

Explanation

Choice D rationale
When assessing a patient with an altered level of consciousness, the nurse’s initial action should be to assess the patient’s response to pain. This is a fundamental part of the neurological examination and can provide valuable information about the patient’s level of consciousness and neurological function. Pain response can be assessed by applying a painful stimulus, such as a pinch, and observing the patient’s reaction.
Choice A rationale
Assessing the patient’s ability to follow complex commands is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. This assessment requires a higher level of cognitive function and may not be possible in a patient with significantly altered consciousness.
Choice B rationale
Assessing the patient’s judgment is an important part of the mental status examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. Like the ability to follow complex commands, judgment requires a higher level of cognitive function and may not be assessable in a patient with significantly altered consciousness.

Choice C rationale
Assessing the patient’s verbal response is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. The patient’s ability to speak and the content of their speech can provide important information about their neurological function, but this assessment may not be possible in a patient with significantly altered consciousness.

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The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL. How many mL should the nurse administer per dose? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

Correct Answer is ["4 "]

Explanation

The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Correct Answer is D

Explanation

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