The nurse enters the room and the client begins to have a seizure while sitting in a chair. Rank the nursing interventions in order beginning with the nurse's first action
1. Call for additional help.
2. Maintain the client's airway.
3. Guide the client to the floor.
4. Clear away hazardous objects.
1, 3, 2, 4
1. The nurse begins by calling for help because the nurse should remain with the client to observe the seizure, maintain the airway, and prevent injury.
3. The client needs to be guided to the floor to prevent injury because of falling from the chair.
2. Once the client is in a safe location, the nurse observes the client for impaired airway or breathing. The nurse implements nursing care to maintain the airway, such as positioning the head or jaw, if implementing the intervention avoids client injury; airways are not inserted during a seizure unless the client's jaw relaxes enough to do so safely.
4. Finally, the nurse clears away objects that can lead to client injury, including furniture and equipment.
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