A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

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and then

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A. Measure the duration of the seizure. Monitoring the duration of a seizure is critical in determining whether it is self-limiting or prolonged. Seizures lasting longer than five minutes may indicate status epilepticus, requiring emergency intervention. Documenting the start and end times helps guide appropriate medical management.
B. Restrain the client's arms and legs to prevent injury. Restraining a client during a seizure can cause musculoskeletal injury or increase agitation. Instead, the nurse should ensure the client is in a safe position, remove nearby hazards, and allow the seizure to run its course while protecting the head.
C. Insert an oral airway into the client's mouth. Forcing an airway device or object into a seizing client's mouth can cause oral trauma, aspiration, or obstruction. The priority is to maintain a patent airway by positioning the client on their side to allow secretions to drain and prevent aspiration.
D. Lower the side rails of the bed when the seizure begins. Lowering the side rails increases the risk of the client falling out of bed during convulsions. If the client is already in bed, keeping the side rails up and padded can help prevent injury while allowing safe observation of the seizure activity.

A. Ask the provider to spell out the name of the medication. Asking the provider to spell out the name of the medication is important to ensure accuracy and prevent medication errors. This step helps clarify any potential confusion regarding similar-sounding medications or names, reducing the risk of administering the wrong drug.
B. Withhold the medication until the provider signs the prescription. Withholding the medication until the provider signs the prescription is not necessary. Telephone prescriptions are valid and can be administered after being documented appropriately, provided that the nurse follows institutional policies regarding the signing of prescriptions. This means that the nurse should not delay necessary medication administration based on awaiting a signature.
C. Record the date and time of the telephone prescription. Recording the date and time of the telephone prescription is essential for accurate medical documentation. This information is critical for maintaining an accurate medication administration record and for legal purposes, ensuring that there is a clear timeline of the prescription order.
D. Request that the provider confirm the read-back of the prescription. Requesting that the provider confirm the read-back of the prescription is a crucial step in ensuring the accuracy of the prescription. The read-back method helps confirm that the nurse understood the prescription correctly and prevents potential errors by allowing the provider to verify the information relayed.
E. Instruct another nurse to record the prescription in the medical record. Instructing another nurse to record the prescription in the medical record is not appropriate. The nurse who received the telephone prescription should document it to maintain accountability and ensure accurate record-keeping. This promotes responsible practice and avoids miscommunication regarding the prescription details.