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 D, C, A, B
Explanation
- A 12-year-old child with a history of asthma is wheezing and complaining of shortness of breath. Wheezing and shortness of breath indicate respiratory distress, which can be a medical emergency for a child with asthma. Prompt intervention and assessment of the child's respiratory status are crucial.
- A 7-year-old child who has type 1 diabetes mellitus is experiencing extreme hunger and shakiness. These symptoms may indicate hypoglycemia, which requires immediate attention to prevent further complications. The PN should assess the child's blood glucose levels and provide appropriate treatment.
- A 10-year-old child with bleeding lacerations on both knees after falling on the playground. While bleeding lacerations require attention, they are not immediately life-threatening or likely to cause severe complications. However, the PN should still address this child's injuries promptly and provide appropriate wound care.
- A 5-year-old child is crying uncontrollably because of an incontinent bowel episode. While the child's distress is significant, it does not indicate an immediate life-threatening condition or urgent medical need. The PN should provide comfort, and reassurance, and assist with appropriate hygiene measures for the child.
Prioritizing care in this order ensures that the most urgent and potentially life-threatening conditions are addressed first, followed by those requiring immediate attention but with a lower risk of complications. Finally, the PN can attend to the client with a condition that, while distressing, is not immediately life-threatening or urgent.
Correct Answer is B
Explanation
Choice A: Document the client's loss of memory in the record.
While it's important to document changes in a patient's condition, this should not be the first action. The confusion might be temporary and due to the new environment. It's crucial to first address the patient's immediate needs.
Choice B: Remind the client what day of the week it is.
This is the best action to take. The patient is likely experiencing "relocation stress syndrome," which can cause confusion and disorientation in a new environment. Reminding her of the day can help reorient her and alleviate her confusion.
Choice C: Encourage the client to rest during the day.
While rest is important, it doesn't directly address the patient's confusion about the day of the week. Furthermore, excessive daytime sleep can disrupt the patient's sleep-wake cycle and potentially exacerbate confusion.
Choice D: Notify the family of the change in the client's condition.
While it's important to keep the family informed, this should not be the first action. The nurse should first address the patient's confusion and monitor her to see if the confusion persists or improves.
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