A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?
a. Start fluids via a large-bore catheter.
b. Turn the client's head to the side.
c. Administer IV push diazepam.
d. Prepare to intubate the client.
ANS: B
The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
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The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
The nurse educator is teaching a group of nursing students about factors that increase the risk for premature birth. Which statements are appropriate for the educator to include? Select all that apply
A) "Married women are at an increased risk for giving birth to a premature infant." B) "Single women are at an increased risk for giving birth to a premature infant." C) "Lesbians have an increased risk for premature labor." D) "Adolescent clients are at an increased risk for giving birth to a premature infant." E) "Pregnancy after the age of 33 years increases the risk for premature labor."
The greatest risk to the newborn after an elective cesarean birth is:
a. trauma due to manipulation during delivery. b. tachypnea due to maternal anesthesia. c. prematurity due to miscalculation of gestation. d. tachycardia due to maternal narcotics.
Which patient would need enhanced skin care precautions?
a. Patient who has one unformed stool after a bolus of tube feeding b. Patient who has an unformed stool followed by a formed stool 3 hours later c. Patient who reports cramping and nausea followed by an unformed stool d. Patient who reports no abdominal discomfort but has had three unformed stools in 8 hours