A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse’s priority?
Loosen restrictive clothing.
Position the child side-lying.
Place a pillow under the child’s head.
Clear the area of hazards.
The Correct Answer is B
Choice A rationale
Loosening restrictive clothing can help ensure the child is comfortable and can breathe easily during a seizure. However, it is not the priority action. The primary concern during a tonic- clonic seizure is to maintain the child’s airway and prevent aspiration, especially if the child is vomiting.
Choice B rationale
Positioning the child side-lying is the priority action. This position helps maintain an open airway and allows any vomit or secretions to drain out of the mouth, reducing the risk of aspiration.
Choice C rationale
Placing a pillow under the child’s head can provide comfort and prevent head injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
Choice D rationale
Clearing the area of hazards is important to prevent injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
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Correct Answer is C
Explanation
Choice A rationale
Regular insulin should not be withheld during illness. When a person with type 1 diabetes is sick, their body may produce more glucose due to stress and infection, leading to hyperglycemia. Therefore, it is crucial to continue taking insulin to manage blood glucose levels effectively.
Choice B rationale
Insulin should not be stored in the freezer. Freezing insulin can cause it to degrade and lose its effectiveness. Insulin should be stored in the refrigerator at a temperature between 2°C and 8°C (36°F and 46°F) until it is opened. Once opened, it can be kept at room temperature for a specified period, usually around 28 days.
Choice C rationale
The target range for morning blood glucose levels in children with type 1 diabetes is typically between 90 and 130 mg/dL. Maintaining blood glucose within this range helps to prevent both hyperglycemia and hypoglycemia, ensuring better overall diabetes management and reducing the risk of complications.
Choice D rationale
Eating a snack before physical activity is important for children with type 1 diabetes to prevent hypoglycemia. Physical activity can lower blood glucose levels, so having a snack that contains carbohydrates can help maintain stable blood glucose levels during exercise.
Correct Answer is B
Explanation
Choice A rationale
Giving an oral rehydration solution is not appropriate without first assessing the infant. Projectile vomiting in a 2-month-old could indicate a serious condition such as pyloric stenosis, which requires medical evaluation.
Choice B rationale
Bringing the baby to the clinic today is the appropriate response. Projectile vomiting in an infant can be a sign of a serious condition that requires prompt medical evaluation and treatment.
Choice C rationale
Switching to a different formula is not appropriate without first assessing the infant. Projectile vomiting could indicate a serious condition that needs to be evaluated by a healthcare provider.
Choice D rationale
Burping the baby more frequently during feedings may help with minor feeding issues, but it is not appropriate advice for projectile vomiting. The infant needs to be evaluated by a healthcare provider to determine the cause of the vomiting.