What is the first nursing action for a client who develops a seizure?

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for a client with a suspected myocardial infarction as it helps dilate coronary arteries, improving blood flow to the heart muscle. This helps reduce chest pain and minimize myocardial damage. Administering fluids (B) may be necessary but not the priority. Placing the client in a sitting position (C) could worsen symptoms. Administering aspirin (D) is important but not as immediate as nitroglycerin for acute pain relief.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Correct Answer: D

Rationale: The correct answer is D: Urologist consult. This is the appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus because a urologist is an expert in diagnosing and managing issues related to the genitourinary system. They can perform a thorough evaluation, order appropriate tests (such as imaging studies), and provide the necessary treatment for any potential trauma. Option A (Insert a Foley catheter) could worsen the trauma if there is an underlying injury. Option B (In and out catheter specimen) and Option C (Voided urine specimen) focus on specimen collection and do not address the potential trauma, making them inappropriate interventions in this situation. Consulting a urologist ensures proper assessment and management of the suspected genitourinary trauma.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.

Correct Answer: D

Rationale: The correct answer is D: A high-fat meal. After gastric resection, high-fat meals are likely to cause rapid gastric emptying due to the delayed gastric emptying effect of fats. Fats take longer to digest compared to other nutrients, leading to slower emptying of the stomach contents. This can result in rapid emptying of the stomach post-resection. A: A high-protein meal does not necessarily cause rapid gastric emptying as proteins are digested at a moderate pace. B: A large meal regardless of nutrient content may lead to slower gastric emptying due to the increased volume. C: A high-carbohydrate meal can promote quicker gastric emptying, but it is not as likely to cause rapid emptying as high-fat meals post-gastric resection.

Correct Answer: D

Rationale: The correct answer is D. When a client refuses medication, the nurse should document the refusal for legal and communication purposes. Informing the healthcare provider ensures ongoing assessment and potential alternatives. Choice A lacks communication with the healthcare team. Choice B may not address the underlying issue. Choice C assumes alternative treatment is necessary without further evaluation.

Correct Answer: B

Rationale: The correct answer is B: Monitor abdominal pain. This is the priority assessment for a client with acute pancreatitis because it helps determine the severity of the condition and guides the treatment plan. Abdominal pain is a key symptom of pancreatitis and monitoring its intensity, location, and changes over time is crucial. Assessing vital signs (choice A) is important but secondary to monitoring pain. Monitoring serum amylase levels (choice C) is relevant for diagnosis but not immediate priority. Performing a CT scan (choice D) may be necessary later for further evaluation but is not the initial priority in managing acute pancreatitis.

Correct Answer: A

Rationale: The correct answer is A (Every 24 hours) because TPN solutions are at high risk for contamination, making it crucial to change the tubing frequently to prevent infection. Changing the tubing every 24 hours helps maintain sterility and reduces the risk of microbial growth. Choices B, C, and D are incorrect because prolonging the tubing change interval increases the likelihood of bacterial colonization and poses a higher risk of infection for the patient receiving TPN. It is essential to adhere to the recommended 24-hour tubing change frequency to ensure patient safety and minimize the potential for complications.