A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?
Apply oxygen by nasal cannula.
Turn the client to a lateral position.
Administer an anticonvulsant medication.
Check the client's oxygen saturation.
The Correct Answer is B
A. Apply oxygen by nasal cannula: Applying oxygen can be beneficial but is not the immediate priority during an active seizure. Protecting the airway comes first.
B. Turn the client to a lateral position: This action prevents aspiration by keeping the airway clear if the client vomits or has excessive secretions.
C. Administer an anticonvulsant medication: Medications may be necessary later, but immediate safety and airway protection take precedence.
D. Check the client’s oxygen saturation: Monitoring oxygen saturation is important but should follow positioning to ensure airway protection.
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Correct Answer is ["A","D"]
Explanation
A. Clear the area of hard objects: This prevents injury to the child during the seizure.
B. Place a tongue depressor in the child's mouth: This is contraindicated as it can cause injury to the oral cavity or obstruct the airway.
C. Place the child in prone position: This position is unsafe during a seizure and could compromise the airway. The lateral position is recommended to reduce aspiration risk.
D. Loosen restrictive clothing: Loosening clothing promotes easier breathing and comfort during the seizure.
Correct Answer is D
Explanation
A. Pneumococcal conjugate vaccine (PCV): This vaccine is generally completed before the age of 5, so it is not typically administered at this stage.
B. Hepatitis B (HBV): The HBV series is usually completed during infancy and early childhood, so it is not needed at 5 years if the child is up to date.
C. Haemophilus influenzae type B (Hib): Hib is typically completed by 18 months of age and is not required for pre-kindergarten.
D. Measles, mumps, and rubella (MMR): A second dose of MMR is typically required at 4-6 years, aligning with pre-kindergarten vaccination schedules.