A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?

Suction equipment

Backboard

Padded tongue blades

Wrist restraints

Answer and Explanation

The Correct Answer is A

Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.

Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.

Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.

Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.

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Correct Answer is D

Explanation

Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.

Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.

Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.

Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.

A. Place the client in high-Fowler's position. B. Administer heparin to the client. C. Encourage the client to cough and deep breathe. D. Obtain the client's vital signs.

Correct Answer is A

Explanation

Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.

Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.

Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.

Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.

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A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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