A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Explanation & Rationale
A. Perform a neurologic check is incorrect as the first action because a neurologic assessment is conducted after the seizure has ended to evaluate postictal status. Performing it during the seizure does not protect the client from immediate harm. B. Obtain the client's vital signs is incorrect because vital signs are assessed after the seizure. Immediate priorities focus on safety and airway protection during the seizure itself. C. Notify the rapid response team is incorrect as the first action unless the seizure is prolonged (>5 minutes) or the client is in distress. Standard tonic-clonic seizures require nurse intervention for safety first. D. Turn the client on their side is correct. Placing the client in the lateral (recovery) position helps maintain a patent airway, reduces the risk of aspiration, and allows secretions to drain. This is the highest priority action during a seizure, addressing the immediate risk to the client’s airway and safety.