Nokea
A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Insert an oral airway into the client's mouth.
- B. Lower the side rails of the bed when the seizure begins.
- C. Measure the duration of the seizure.
- D. Restrain the client's arms and legs to prevent injury.
Correct Answer: C
Rationale: Measuring seizure duration aids in assessing severity and guiding treatment. Inserting airways, lowering rails, or restraining can cause injury or complications.
You may also like to solve these questions
A nurse is reinforcing teaching with a client who has a new prescription for losartan. Which of the following statements should the nurse include?
- A. You should take this medication with a high-potassium meal.
- B. You might experience dizziness while taking this medication.
- C. You need to limit your exercise while taking this medication.
- D. You can take this medication at any time of day.
Correct Answer: B
Rationale: Losartan can cause dizziness due to blood pressure lowering, a key safety concern. Potassium meals, exercise limits, or flexible timing aren't primary considerations.
A nurse is reinforcing teaching with a client who has a new prescription for tramadol. Which of the following instructions should the nurse include?
- A. Take this medication with food to prevent nausea.
- B. You might experience constipation while taking this medication.
- C. You should avoid driving until you know how this medication affects you.
- D. You can increase the dose if your pain persists.
Correct Answer: B,C
Rationale: Tramadol can cause constipation, and its sedative effects warrant avoiding driving initially. Food may help nausea but isn't required, and dose increases need provider approval.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.
A nurse is reinforcing teaching with a client who has gout and a new prescription for allopurinol. Which of the following statements should the nurse include?
- A. You should limit your intake of vitamin C.
- B. You might experience a skin rash while taking this medication.
- C. You can take this medication with an antacid to reduce stomach upset.
- D. You should avoid drinking coffee while taking this medication.
Correct Answer: B
Rationale: Allopurinol can cause rashes, a potential sign of serious reactions. Vitamin C, antacids, or coffee don't significantly interact with allopurinol.
A nurse is reinforcing teaching with a client who has a new prescription for lorazepam. Which of the following statements should the nurse include?
- A. Take this medication every morning.
- B. You might feel dizzy while taking this medication.
- C. You need to increase your fluid intake.
- D. You can take this medication with an antacid.
Correct Answer: B
Rationale: Lorazepam can cause dizziness, a safety concern. Timing varies, fluid increase isn't needed, and antacids don't interact significantly.