a client is experiencing a tonic clonic seizure what is the nurses priority intervention

HESI LPN

Adult Health Exam 1 Chamberlain

1. During a tonic-clonic seizure, what is the nurse's priority intervention?

A. Insert an oral airway
B. Administer oxygen via nasal cannula
C. Restrain the client's arms and legs
D. Protect the client's head from injury

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.

2. A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?

A. The neck extended backward using a rolled towel behind the neck
B. Prone position using pillows to support both arms outward from the torso
C. Side-lying position using pillows to support the abdomen and back
D. The neck forward using pillows under the head and sandbags on both sides

Correct answer: D

Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.

3. A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?

A. Rotate injection sites to prevent tissue damage
B. Inject insulin into the same site to increase absorption
C. Only use insulin pens
D. Mix different types of insulin in the same syringe

Correct answer: C

Rationale: The correct answer is to only use insulin pens. This is because insulin pens provide a convenient and accurate way to administer insulin. Rotating injection sites is important to prevent tissue damage and promote consistent insulin absorption, making choice A incorrect. Injecting insulin into the same site can lead to lipodystrophy and is not recommended, making choice B incorrect. Mixing different types of insulin in the same syringe can alter their action profiles and is generally not recommended, making choice D incorrect.

4. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

A. Stand the client to void and run tap water within hearing distance before catheterizing
B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

5. What is the most important aspect of colostomy care to teach the client?

A. Change the colostomy bag only when necessary
B. Eat a low-residue diet
C. Assess the stoma for color and swelling
D. Irrigate the colostomy only if advised by a healthcare provider

Correct answer: C

Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.