A nurse in a provider's office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.

i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.

ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.

Rationale for incorrect answers:

remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.

reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.

administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.

Correct answer: The client is most at risk of developing atelectasis and paralytic ileus.

Rationale for correct answers:

• atelectasis: The client is 6 hours postoperative, drowsy from morphine, and has shallow breath sounds. Narcotic pain medications suppress the cough reflex and decrease deep breathing, leading to the collapse of alveoli (atelectasis). This is further evidenced by the slight drop in oxygen saturation (95% to 94%) and the decrease in respiratory rate.
• paralytic ileus: The client has hypoactive bowel sounds and has undergone abdominal surgery. General anesthesia and opioid analgesics (morphine) both slow down intestinal motility. If peristalsis does not return or remains severely suppressed, the client can develop a paralytic ileus (a non-mechanical bowel obstruction).

Rationale for incorrect answers:

• urinary tract infection: This is not the primary risk at this time. The client’s urinary catheter was removed, and the client has already successfully voided 350 mL of clear urine, indicating good bladder function and a low immediate risk for UTI.
• delayed wound healing: While a risk for any surgical client, this client denies diabetes and peripheral vascular disease (Exhibit 1), which are the primary risk factors for delayed healing. The dressing is currently dry and intact.
• deep vein thrombosis: Although a general risk for postoperative clients, this client is wearing sequential compression devices (SCDs) and has even pedal pulses with no edema, indicating that preventive measures are in place and working.