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 A
Explanation
Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.
Correct Answer is B
Explanation
Choice A rationale
It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child’s ear.
Choice B rationale
If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps.
Choice C rationale
It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time.
Choice D rationale
Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.
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