Question

A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (Select all that apply.)

a) Ensure a patent airway.
b) Place the client in a supine position.
c) Administer a sedative medication.
d) Turn the client to the side.
e) Provide oxygen therapy.

Answer 1

In the event of a tonic-clonic seizure with cyanosis, the nurse should ensure a patent airway, turn the client to the side and provide oxygen therapy. Laying the client supine is not advised, and sedative medication requires physician's guidance.

Step-by-step explanation:

When a client is having a tonic-clonic seizure and becomes cyanotic, the nurse should take several immediate steps to ensure the client's safety and manage the situation. The following actions are recommended:

• (a) Ensure a patent airway: This is crucial as a blocked airway can lead to complications including further cyanosis and hypoxia.
• (d) Turn the client to the side: This helps prevent aspiration should the client vomit and aids in maintaining a clear airway.
• (e) Provide oxygen therapy: If the client is cyanotic, they are not receiving enough oxygen, so administration of oxygen can be essential.

Placing the client in a supine position is not recommended as this can increase the risk of aspiration. The administration of sedative medication should typically be done under physician guidance and may not be the immediate action during an active seizure if the medication is not already prescribed for seizure control.