A charge nurse is teaching a newly licensed nurse about medication administration.
Which of the following information should the charge nurse include?

Choice A rationale:

"Since I retired, I have entered many gardening competitions." This statement indicates compensation as a defense mechanism. Compensation involves emphasizing personal strengths in one area to shift focus from failure or weakness in another. In this case, the client is finding fulfillment and recognition in gardening competitions after retiring, compensating for the loss of work-related identity.

Choice B rationale:

Expressing relief about retirement due to negative work experiences doesn’t necessarily indicate compensation. It could be a coping mechanism, but it doesn't align with the compensation defense mechanism, which involves overachieving in one area to compensate for deficiencies in another.

Choice C rationale:

Choice D rationale:

Journaling about career accomplishments after layoffs indicates sublimation, not compensation. Sublimation is a defense mechanism where unacceptable impulses or behaviors are transformed into socially acceptable actions or pursuits, like channeling frustration or disappointment into creative or productive activities such as journaling.

The correct answer is choice D: Insert an IV saline lock.

Choice D rationale: Inserting an IV saline lock is an appropriate nursing intervention for a client with a tonic-clonic seizure. This allows for quick access to administer intravenous medications, such as anticonvulsants, in case the client experiences another seizure.

Choice A rationale: Providing a tracheostomy tray at the bedside is not necessary for seizure precautions. While maintaining a patent airway is essential during a seizure, it can typically be managed with proper positioning and suctioning if necessary.

Choice B rationale: Placing the client in a supine position is not recommended for seizure precautions. Instead, the client should be placed in a semi-prone or lateral position to promote drainage of secretions and prevent aspiration.

Choice C rationale: Placing a plastic tongue depressor at the client's bedside is not an appropriate intervention. Attempting to insert an object into the client's mouth during a seizure can cause injury and is not recommended.

In summary, the nurse should include inserting an IV saline lock as part of the plan of care for a client who has experienced a tonic-clonic seizure. This will allow for rapid administration of medications, if necessary, while prioritizing client safety and adhering to seizure precautions.