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

Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

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

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. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

3. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

4. The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?

Correct answer: C

Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.

5. A client with a history of peptic ulcer disease (PUD) is prescribed omeprazole (Prilosec). What is the primary action of this medication?

Correct answer: B

Rationale: The correct answer is B: Reduces gastric acid production. Omeprazole is a proton pump inhibitor that works by reducing gastric acid production, thereby helping to heal ulcers. While neutralizing stomach acid is associated with antacids, forming a protective barrier over ulcers is more characteristic of medications like sucralfate. The action described in choice D, increasing gastric mucus production, is not the primary mechanism of action of omeprazole in treating peptic ulcer disease.

Similar Questions

A client with asthma is prescribed a corticosteroid inhaler. What instruction should the nurse give about the inhaler?
The nurse is providing preoperative teaching to a client who will undergo a thyroidectomy. What information should the nurse include about postoperative care?
The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse’s priority action?
The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?
The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses