While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Observe for prolonged periods of apnea.

Observe for lacerations to the tongue.

Document details of the seizure activity.

Evaluate for evidence of incontinence.

Answer and Explanation

The Correct Answer is A

A.   This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
B.   This intervention is crucial for assessing potential injury to the client's mouth or tongue, which can occur during a seizure due to involuntary muscle movements. However, before assessing for lacerations, the nurse should prioritize ensuring the client's safety.
C.   Documenting details of the seizure activity is important for maintaining accurate medical records and providing information to the healthcare team. However, before documenting details of the seizure, the nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure. Therefore, while documentation is essential, it may not be the first intervention to implement.
D.   While evaluating for incontinence is important for addressing the client's immediate needs and ensuring comfort, it may not be the first intervention to implement. The nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure.

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Correct Answer is B

Explanation

B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage.
A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.
C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.
D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.

A. Review need for pneumococcal vaccine. B. Implement bleeding precautions. C. Place the client in protective isolation. D. Assess vital signs every 4 hours.

Correct Answer is C

Explanation

C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.

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While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Correct Answer is C

Explanation

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