Upon finding a school-age child having a seizure, what should be the nurse’s first action after lowering the client to the floor?
Turn the client to a lateral position.
Administer an anticonvulsant medication.
Apply oxygen by nasal cannula.
Check the client’s oxygen saturation.
The Correct Answer is A
Choice A rationale
The first action a nurse should take upon finding a school-age child having a seizure is to ease the person to the floor and turn the person gently onto one side. This will help the person breathe and can prevent injury.
Choice B rationale
Administering an anticonvulsant medication is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice C rationale
Applying oxygen by nasal cannula is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice D rationale
Checking the client’s oxygen saturation is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1170 "]
Explanation
Step 1 is to convert all fluid intake to mL.
Using the conversion factor 1 oz = 30 mL7 and 1 cup
= 240 mL8, we get: 1 cup of coffee = 240 mL 4 oz of orange juice = 4 × 30 mL = 120 mL 3 oz of water = 3 × 30 mL = 90 mL 1 cup of flavored gelatin = 240 mL 1 cup of tea = 240 mL 5 oz of broth = 5 × 30 mL = 150 mL 3 oz of water = 3 × 30 mL = 90 mL Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL So, the nurse should record a fluid intake of 1170 mL.
Correct Answer is D
Explanation
Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.
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