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 ["A","B","C","F","G"]
Explanation
Ataxia: Phenytoin can cause problems with coordination and balance, leading to ataxia. The PN should monitor the client for unsteady gait or difficulty with movements.
Drowsiness: Phenytoin can cause drowsiness or sedation. The PN should observe the client for excessive sleepiness or difficulty staying awake.
Altered blood coagulation: Phenytoin can affect blood clotting factors, potentially leading to altered blood coagulation. The PN should assess the client for any signs of bleeding or bruising.
Vertigo: Phenytoin can cause dizziness or vertigo, which is a spinning sensation. The PN should be alert for complaints of dizziness or any difficulty with balance.
Visual disturbances: Phenytoin can cause visual disturbances, such as blurred vision or double vision. The PN should monitor the client's vision and report any changes.
The following options are incorrect regarding the toxic effects of phenytoin:
- Anxiety: Anxiety is not a recognized toxic effect of phenytoin. However, it is important to assess the client for any signs of anxiety or emotional changes.
- Aphasia: Aphasia refers to a language impairment and is not typically associated with the toxic effects of phenytoin.
- Vomiting: While phenytoin can cause gastrointestinal side effects, such as nausea and vomiting, it is not directly related to its toxic effects. However, the PN should still monitor the client for any signs of nausea or vomiting.
Correct Answer is ["A","D","E"]
Explanation
Since the pregnant woman is vegetarian and does not eat meat, the practical nurse (PN) should provide alternative sources of iron-rich foods. Lentils and black beans are excellent vegetarian sources of iron and can be added to soups to increase iron intake (option a).
Oatmeal is a good choice for breakfast as it is often fortified with iron (option d). This can help supplement iron intake in the diet.
Green leafy vegetables, such as spinach, kale, and broccoli, are also rich in iron and should be increased in the client's diet (option e).
Option b, which suggests eating red meat just until the anemia is resolved, is not appropriate for a vegetarian client.
Option c, taking two prenatal vitamins with iron daily, is not necessary unless specifically advised by the healthcare provider. It is important to follow the prescribed dosage of medication and supplements as directed by the healthcare provider.
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