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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["0.9 "]

Explanation

Step 1: We are instructed to administer tobramycin 35mg IM every 8 hours. The available supply is 40mg in a 1 mL vial.

Step 2: We need to find out how many mL’s should the nurse administer. Step 3: We can set up a proportion to solve this.

Step 4: If 40mg is equivalent to 1mL, then 35mg is equivalent to x mL. Step 5: Solving for x gives us x = (35mg ÷ 40mg) × 1mL.

Step 6: Calculating the above expression gives us x = 0.875 mL.

Step 7: Rounding our answer to the nearest tenth, we get 0.9 mL. So, the nurse should administer 0.9 mL.

A. Twenty to thirty minutes after the onset of symptoms. B. As soon as the patient senses the onset of the symptoms. C. As soon as the patient’s pain becomes unbearable. D. When the patient senses their symptoms are peaking.

Correct Answer is B

Explanation

Choice B rationale
Patients who experience severe cluster headaches should be instructed to take medications as soon as they sense the onset of symptoms. Cluster headaches are characterized by severe, debilitating pain that reaches peak intensity within a short period of time, often within 15 minutes. Therefore, early intervention is crucial to manage the pain effectively.
Choice A rationale

Waiting twenty to thirty minutes after the onset of symptoms to take medications may not be effective for cluster headaches. The pain of a cluster headache often reaches peak intensity within 15 minutes, so delaying medication could result in unnecessary suffering.
Choice C rationale
Waiting until the patient’s pain becomes unbearable is not recommended for managing cluster headaches. The goal of treatment is to prevent or reduce pain, not to wait until it becomes unbearable.
Choice D rationale
Taking medications when the patient senses their symptoms are peaking is not the most effective strategy for managing cluster headaches. Given the rapid onset and severe pain associated with cluster headaches, medications should be taken as soon as the patient senses the onset of symptoms.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are instructed to administer tobramycin 35mg IM every 8 hours. The available supply is 40mg in a 1 mL vial. How many mL’s should the nurse administer? Round your answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

Correct Answer is ["0.9 "]

Explanation

A nurse is caring for a patient who experiences severe cluster headaches. At what point in the course of a new headache should the patient be instructed to take medications?

Correct Answer is B

Explanation

During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

A nurse is admitting a client diagnosed with herpes simplex virus encephalitis. Which medication would the nurse anticipate the healthcare provider to order for treatment?

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

The nurse is caring for a client who is suspected of meningitis. After reviewing lab results, the nurse will anticipate that the provider will prescribe which medications to treat the meningitis?

A nurse is teaching a group of older adults about risk factors for developing a stroke. Which non-modifiable risk factors should the nurse include in the teaching?

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?