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
Explanation
The action the practical nurse (PN) should take in this situation is to administer a prescribed PRN (as needed) dose of analgesic.
Severe burning pain along the right side of the trunk is a common symptom of herpes zoster (shingles). Managing the client's pain is an important aspect of care to provide comfort and promote healing. Administering a prescribed PRN dose of analgesic will help alleviate the client's pain and improve their overall well-being. It is crucial to follow the client's prescribed medication regimen and provide pain relief as needed.
The other options are not the most appropriate actions in this situation:
B. Notifying the nursing supervisor of uncontrolled pain may be necessary if the client's pain persists despite appropriate interventions. However, the first step should be to administer an analgesic to address the immediate pain.
C. Giving the next prescribed dose of antiviral medication is important in the treatment of herpes zoster, but it does not directly address the client's current severe burning pain. Analgesics are specifically designed to alleviate pain symptoms.
D. Obtaining an oxygen tank for home administration is not indicated for the management of pain associated with herpes zoster. Oxygen therapy is typically used for respiratory or circulatory conditions and would not be the appropriate intervention for the client's symptom of severe burning pain.
Correct Answer is ["C","E"]
Explanation
C. Regularly selects salty snacks to eat in the evening: Consuming excessive amounts of sodium (found in salty snacks) can increase blood pressure and contribute to the development of hypertension.
E. Chews tobacco while playing baseball every weekend: Tobacco use, including chewing tobacco, is associated with an increased risk of hypertension and other cardiovascular diseases.
The other choices are incorrect because they do not directly contribute to an increased risk of hypertension:
A. Drinks a protein supplement for breakfast every day: Consuming a protein supplement for breakfast does not necessarily increase the risk of hypertension. However, it is important to note that some protein supplements may contain added sodium, which can contribute to hypertension if consumed in excessive amounts.
B. Eats eight ounces of nonfat yogurt for lunch daily: Eating nonfat yogurt is generally considered a healthy food choice. However, unless the yogurt is high in added sodium, it would not significantly increase the risk of hypertension.
D. Walks briskly for two miles every day after work: Regular exercise, such as brisk walking, is generally beneficial for cardiovascular health and can help lower blood pressure. It is unlikely to increase the risk of hypertension.
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