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Daily #102 · Neurological · Archive

NCLEX-RN® question of the day

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The question

A 28-year-old client with a known seizure disorder is brought to the emergency department by paramedics. The paramedics report the client has been experiencing continuous tonic-clonic seizure activity for approximately 35 minutes without regaining consciousness between episodes. Upon arrival, the client's oxygen saturation is 88% on room air and temperature is 38.9°C (102°F). Which nursing intervention is the HIGHEST priority at this time?

  1. Place the client in a lateral recumbent position and pad side rails
  2. Insert an indwelling urinary catheter to monitor urine output for myoglobinuria
  3. Apply supplemental oxygen and prepare to assist with airway management
  4. Obtain IV access and prepare to administer a benzodiazepine as prescribed

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