HESI COMPREHENSION EXAM 2
1. A nurse is caring for the client who begins to exhibit seizure activity while in bed. Which of the following actions does the... [Show More] nurse implement to care for the client? Select all that apply.
A. Observing and timing the seizure Correct
B. Loosening any restrictive clothing Correct
C. Turning the client’s head to the side Correct
D. Removing the pads on the side rails
E. Inserting an airway into the client’s mouth
F. Removing objects that might injure the client from the vicinity Correct
Rationale: Client safety is a priority for the client experiencing a seizure. Nursing actions during a seizure include providing privacy, loosening restrictive clothing, removing the pillow, raising the padded side rails on the bed, removing objects that might cause injury to the client, and placing the client on the side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. (The nurse should not insert anything into the client’s mouth.) The nurse also observes, documents, and times the seizure. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head against injury; and moves furniture that may injure the client if he or she were to come in contact with it during the seizure.
Test-Taking Strategy: Evaluate this question from the perspective of causing harm. No harm can come to the client from any of the options except for removal of the padded side rails and insertion of an airway into the client’s mouth. Review care of the client experiencing a seizure if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Critical thinking for collaborative care (6th ed., p. 959). Philadelphia: Saunders.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 383727420
Which of the following infection-control measures would the nurse implement for a client in whom smallpox is diagnosed? Select all that apply.
B. Droplet Correct
C. Contact Correct
D. Standard Correct
E. Protective isolation
Rationale: Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented [Show Less]