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    Hesi rn medical surgical nursing proctored exam
    Select All That Apply

    Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

    Explanation & Rationale

    A. This is important to prevent injury but is not the priority at this time. B. This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation. C. This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient. D. This is not necessary at this point and may not be feasible during the emergency situation. E. While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels. F. Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

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