A client has a prescription for seizure precaution. Which intervention should the nurse include in the plan of care?
Keep the bed in the highest position
Keep seizure medication at the bedside at all times
Keep very bright lights in the client's room during the night
Keep the bed locked in the lowest position .
Keep the bed locked in the lowest position .
The Correct Answer is B
Choice A is incorrect. While keeping the bed in a high position can minimize fall risk, it is not a specific precaution for preventing seizures. In fact, some types of seizures can be triggered by sudden changes in position.
Choice C is incorrect. Bright lights can worsen seizure activity and should be avoided, especially during the night when the client is more likely to be photosensitive.
Choice D is incorrect. Locking the bed in the lowest position can increase fall risk and is not a specific precaution for preventing seizures.
Rationale for Choice B:
Having seizure medication readily available at the bedside allows for immediate administration in case of a seizure, which can minimize its duration and severity. This is a crucial intervention for seizure precaution.
Keeping the medication within easy reach also ensures prompt administration by healthcare personnel or caregivers, further improving the client's safety and outcome.
Additionally, easy access to the medication empowers the client or caregiver to participate actively in their own care and respond quickly to a potential seizure.
Therefore, based on the importance of immediate access to seizure medication in managing and preventing seizures, Choice B is the most appropriate intervention to include in the client's plan of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Urine collection from an indwelling catheter is a sterile procedure that requires aseptic technique to prevent contamination of the specimen and potential urinary tract infection. Assistive personnel (AP) may not have the necessary training in sterile technique and therefore should not be delegated this task. Additionally, the nurse needs to assess the patient for any signs of urinary tract infection or other complications before collecting the urine specimen, which is within the scope of nursing practice.
Choice B rationale:
Blood collection for PaCO2 (partial pressure of carbon dioxide) is an invasive procedure that requires assessment of the patient's condition, appropriate site selection, and proper technique to ensure accurate results. This task is within the scope of nursing practice and should not be delegated to AP.
Choice C rationale:
Wound drainage collection for culture also requires aseptic technique to prevent contamination of the specimen and ensure accurate results. The nurse needs to assess the wound for signs of infection, choose the appropriate collection method, and ensure proper labeling and transport of the specimen. This task is within the scope of nursing practice and should not be delegated to AP.
Choice D rationale:
Random stool specimen collection is a non-invasive procedure that does not require sterile technique. AP can be trained to collect random stool specimens safely and effectively, following standard precautions for handling body fluids.
Correct Answer is B
Explanation
Choice A rationale:
Delivering meal trays to clients in their rooms is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.
Choice B rationale:
Observing postoperative clients who are confused requires a higher level of skill and knowledge than delivering meal trays. Volunteers are not typically trained to assess and monitor patients for changes in their condition, and they may not be able to recognize and respond to potential emergencies. This task is best assigned to a licensed nurse or other qualified healthcare professional.
Choice C rationale:
Assisting ambulatory clients with meals is another task that can be safely assigned to volunteers. This task involves helping patients with simple activities such as opening food containers and cutting food. Volunteers can be trained to perform these tasks safely and effectively.
Choice D rationale:
Delivering mail is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.
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