a nurse is caring for a client who has experienced a seizure what should the nurse do immediately after the seizure
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?

Correct answer: C

Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.

2. When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Avoid smoking and open flames near oxygen.' This information is crucial to prevent fire hazards when using home oxygen therapy. Smoking and open flames near oxygen can lead to serious accidents. Choice A is incorrect because increasing the oxygen flow rate during activity without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored in a well-ventilated area, not necessarily warm and dry. Choice D is incorrect as oxygen should not be turned off and on by the client, as it can affect the therapy's effectiveness and cause safety issues.

3. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

4. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

5. A client with diabetes mellitus is being taught about foot care. What statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes at all times when out of bed is crucial for clients with diabetes mellitus to protect their feet from injury. Option A is incorrect as soaking feet in warm water can lead to dry skin, making it more susceptible to injuries. Option C is incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Option D is incorrect as cutting toenails straight across is a good practice but is not directly related to preventing foot injuries in clients with diabetes.

Similar Questions

A healthcare professional is reviewing a client's medical history and identifies an increased risk for infections. What risk factor should the healthcare professional include?
A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?
A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?
A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?
A healthcare professional is preparing to administer multiple medications to a client with dysphagia. What action should the healthcare professional take?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses