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
In infants with heart failure, they may have difficulty feeding due to fatigue and increased work of breathing. Allowing the infant to rest before feeding helps conserve their energy and reduces the risk of excessive fatigue during feeding.
The other options are not appropriate interventions for this situation:
A.Weigh before and after feeding: Weighing before and after feeding is not necessary in this case unless specifically ordered by the healthcare provider. It is not directly related to the management of feeding an infant with heart failure.
C.Feed the infant when he cries: Feeding the infant solely based on crying may not be appropriate in this case. It is important to establish a feeding schedule and monitor the infant's signs of hunger and satiety to ensure adequate nutrition and prevent overfeeding.
D.Insert a nasogastric feeding tube: Inserting a nasogastric feeding tube should not be the first intervention unless there is a specific indication or order from the healthcare provider. In this scenario, the focus is on supporting oral feeding and allowing the infant to rest before feeding.
Correct Answer is A
Explanation
The prescription for Ampicillin 500 mg PO q8h means that the client should take 500 mg of Ampicillin orally every 8 hours. "PO" stands for "by mouth," indicating that the medication should be taken orally. The medication is prescribed at 1000, and the next dose is due at 1300 (1:00 PM).
The other options are as follows:
B. Lisinopril 5 mg PO every day: This medication is prescribed to be taken once a day, not every 8 hours. It is not due at 1300.
C. Metformin 1000 mg PO BID: This medication is prescribed to be taken twice a day (BID), but it is not due at 1300. The timing for the next dose depends on when the first dose was administered.
D. Pantoprazole 40 mg PO every day: This medication is also prescribed to be taken once a day, not every 8 hours. It is not due at 1300.
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