Question: After a grand mal seizure, what nursing action is the highest priority?
1. Loosen or remove constricting clothing and protect client from injuring himself or herself.
2. Maintain a patent airway by turning the client on his side and suctioning, if necessary.
3. Remain with the client and administer anticonvulsant medications as ordered by the physician.
4. Describe and record events before the onset of the seizure, during the seizure, and after the seizure.
Rationale: The priority after a grand mal seizure is to maintain a patent airway. The question is asking for a nursing intervention after the seizure is over. The clothes should be loosened so that they do not constrict the client. The nurse may need to remain with the client, and the events of the seizure need to be recorded, but the priority of this question is the airway.
This week’s NCLEX exam practice question came from:
Zerwekh: Illustrated Study Guide for the NCLEX-RN Exam, 7th edition, Chapter 20, page 436, question7
Zerwekh: Illustrated Study Guide for the NCLEX-RN Exam, 7th edition, Chapter 20, page 436, question7
Such a nice post about the MCAT questions..Thanks for sharing.
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