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. Notify the rapid response team: While notifying the rapid response team may be necessary if the seizure is prolonged or complicated, immediate priority actions focus on maintaining the client’s safety during the seizure. Delaying safety measures to call for help could put the client at risk of injury. B. Turn the client on their side: Turning the client on their side helps maintain a patent airway and reduces the risk of aspiration. Ensuring the airway and preventing injury are the highest priorities during a seizure, making this the first action the nurse should take. C. Obtain the client's vital signs: Vital signs should be assessed after the seizure ends, as obtaining them during active seizure activity is not feasible and does not address immediate safety or airway needs. D. Perform a neurologic check: Neurologic assessment is important after the seizure to evaluate the client’s postictal status. However, it is not the first priority, because ensuring airway protection and preventing injury take precedence during the seizure.