what is the most appropriate action for a nurse to take when a patient is experiencing a seizure
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023

1. What is the most appropriate action for a healthcare provider to take when a patient is experiencing a seizure?

Correct answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

2. What is the best nursing intervention for a patient with hyperkalemia?

Correct answer: A

Rationale: The correct answer is to administer potassium-wasting diuretics. Hyperkalemia, which is high potassium levels, is managed by promoting the excretion of potassium from the body. Potassium-wasting diuretics help the kidneys eliminate excess potassium. Encouraging a low-potassium diet (choice B) is important for long-term management but not the immediate intervention for hyperkalemia. Administering potassium supplements (choice C) would worsen the condition by further increasing potassium levels. Administering IV fluids (choice D) may help with hydration but does not directly address the high potassium levels characteristic of hyperkalemia.

3. A client undergoing bariatric surgery is being taught about postoperative dietary changes by a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because avoiding solid foods after bariatric surgery is crucial to prevent complications and promote healing. Choice A is incorrect as carbonated beverages can cause discomfort and should be avoided. Choice B is incorrect as large meals are not suitable after bariatric surgery. Choice D is incorrect as taking small sips of liquids is encouraged to prevent dehydration and promote recovery.

4. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

5. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

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