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 B
Explanation
Antiplatelet medications, such as aspirin or clopidogrel, are prescribed to prevent the formation of blood clots by inhibiting platelet aggregation. These medications can increase the risk of bleeding or prolonged bleeding time. Therefore, when removing the saline lock, applying pressure over the site for several minutes helps to minimize the risk of bleeding and promote hemostasis.
A. Leaving the saline lock in place and notifying the charge nurse may not be necessary unless there are specific concerns or complications related to the client's condition.
C. Encouraging the client to drink additional oral fluids is not directly related to the discontinuation of the saline lock and the potential risk of bleeding associated with antiplatelet medication.
D. Preparing a warm pack to apply after removing the lock is not necessary for this situation. Warm packs are typically used for comfort or to promote circulation, but they are not directly related to the risk of bleeding associated with antiplatelet medication.
Correct Answer is D
Explanation
Regular insulin is the medication of choice for treating DKA. Its main action is to lower blood glucose levels by promoting the uptake of glucose into cells and inhibiting the production of glucose by the liver. Therefore, checking the fingerstick blood glucose level is an important indicator of the effectiveness of the insulin treatment.
A decrease in the blood glucose level indicates that the insulin is working to lower the high blood sugar associated with DKA. This measurement helps the PN assess the response to treatment and adjust the insulin dosage if necessary.
The other actions mentioned are also important assessments in the care of a client with DKA, but they do not specifically evaluate the effectiveness of the insulin dosage:
A. Smelling the client's breath for resolution of a fruity odor is important as it indicates a decrease in ketone production, which is a marker of improving DKA. However, it does not directly evaluate the effectiveness of the insulin dosage.
B. Determining the client's orientation to time and space is part of assessing their neurological status, which is crucial in managing DKA. However, it does not specifically assess the effectiveness of the insulin dosage.
C. Measuring the client's urinary output for an increased volume is important to monitor hydration status and renal function, but it does not directly evaluate the effectiveness of the insulin dosage.
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