The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next?
Begin chest compressions.
Watch the seizure activity and document the time and client movement.
Place pillows around the bed rails to provide padding.
Stop the IV fluids.
Increase the supplemental oxygen to 10 L/min via nasal cannula.
Manually ventilate the client with a bag-valve mask.
Correct Answer : C,E,F
C. Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client may experience uncontrolled movements and convulsions. Placing pillows around the bed rails helps prevent injury by providing padding and cushioning.
E. Increase the supplemental oxygen to 10 L/min via nasal cannula: The client's oxygen saturation is dangerously low at 40%. Increasing the supplemental oxygen to 10 L/min via nasal cannula will help improve oxygenation and prevent hypoxia.
F. Manually ventilate the client with a bag-valve-mask: Since the respiratory rate is only 4 breaths/min, the client is not adequately ventilating on their own. Manual ventilation with a bag-valve mask will provide necessary oxygenation and ventilation support during the seizure.
The other options are not appropriate actions at this time:
- Begin chest compressions: Chest compressions are indicated if the client's heart has stopped or if they are in cardiac arrest. Since the scenario describes a seizure, the client's heart is presumed to be functioning.
- Watch the seizure activity and document the time and client movement: Although documentation is important, during an active seizure, the priority is to ensure the client's safety and provide immediate interventions. Documentation can be done after the seizure has ended.
- Stop the IV fluids: There is no indication to stop the IV fluids based on the given information. IV fluids are generally continued unless there is a specific reason to discontinue them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's complaint of a leg cramp suggests the possibility of a muscle cramp or spasm, which is a common occurrence during labor. Extending the leg and flexing the foot helps stretch and relax the affected muscle, which can alleviate the cramp. This intervention helps relieve the muscle spasm and promotes increased blood circulation to the area, potentially reducing the intensity and duration of the cramp.
A. Elevating the leg above the heart is not necessary for relieving a leg cramp. It may be helpful in certain situations, such as in the case of venous insufficiency or swelling, but it is not the First-line intervention for a leg cramp.
B. Massaging the calf and foot can be beneficial in relieving a leg cramp. However, the initial action should be to extend the leg and flex the foot to actively stretch the affected muscle. If the cramp persists or if additional comfort measures are needed, then the PN may consider massaging the calf and foot.
D. Checking the pedal pulse in the affected leg is not directly related to relieving a leg cramp. It may be a relevant assessment in certain situations, such as suspected circulatory compromise or deep vein thrombosis, but it is not the primary intervention for a leg cramp.
Correct Answer is ["0.75"]
Explanation
To calculate the volume of medication to administer, we can use the following conversion: 1 mg = 1000 mcg
Given that the prescribed dose is 150 mcg/day, we need to convert it to milligrams: 150 mcg = 150/1000 mg = 0.15 mg
Since the medication is available in 0.2 mg/mL vials, we can calculate the volume to administer using the following equation:
Volume (mL) = Dose (mg) / Concentration (mg/mL) Volume (mL) = 0.15 mg / 0.2 mg/mL
Volume (mL) = 0.75 mL
Therefore, the practical nurse (PN) should administer 0.75 mL of the medication.
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