Final answer:
During a tonic-clonic seizure post-surgery, the nurse should ensure patient safety and protect the head, while also calling for assistance. Administering medication or using restraints or oral airways should not be the first response.
Step-by-step explanation:
When a patient with a history of epilepsy experiences a tonic-clonic seizure in the postanesthesia recovery unit (PACU), the nurse's priority is to ensure patient safety. The immediate action the nurse should take while the patient is having the seizure is to protect the head and ensure the patient cannot harm themself. The nurse should also call for assistance. Restraints are not recommended during an active seizure as they can cause injury, and inserting an oral airway can be difficult and dangerous due to the risk of the patient biting down. Administering medication, such as anticonvulsants, should be done under the direction of a physician, and it may not be the first immediate step while the seizure is occurring.