A nurse is caring for a client who has preeclampsia.
Which of the following actions is the nurse’s priority when implementing seizure precautions?
Ensure the call button is within the client’s reach
Place suction equipment at the client’s bedside
Dim the lights in the client’s room
Pad the side rails of the client’s bed
The Correct Answer is B
Choice A rationale: Ensuring the call button is within the client's reach is important for general patient safety and communication, but it is not the highest priority for seizure precautions.
Choice B rationale: Placing suction equipment at the client's bedside is crucial for managing airway secretions during a seizure. Having suction equipment readily available ensures that the client's airway can be cleared promptly, which is vital for maintaining breathing and preventing aspiration.
Choice C rationale: Dimming the lights in the client's room can help reduce stimuli that may trigger seizures, but it is not the most urgent action to take when implementing seizure precautions.
Choice D rationale: Padding the side rails of the client's bed is important to prevent injury during a seizure, but ensuring that suction equipment is available takes priority to maintain airway patency and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
• Hyperemesis gravidarum: The client’s symptoms such as severe nausea and vomiting, inability to retain clear fluids, and positive ketones in urinalysis suggest that she is most likely experiencing hyperemesis gravidarum, a pregnancy complication characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance.
• Actions to take: The nurse should administer the prescribed antiemetic medication to help control the client’s nausea and vomiting. The nurse should also provide IV fluid replacement to correct the client’s dehydration and electrolyte imbalance.
• Parameters to monitor: The nurse should monitor the client’s urine output to assess her hydration status. The nurse should also monitor the client’s electrolyte levels, as electrolyte imbalances can occur with severe vomiting and dehydration. If the client’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Abdominal distention is not typically associated with hypoglycemia. It can be a sign of other conditions such as gastrointestinal issues.
Choice B rationale
Temperature instability can be a sign of hypoglycemia. Hypoglycemia can interfere with the body’s ability to regulate temperature.
Choice C rationale
Acrocyanosis, or blueness of the skin, is a common finding in newborns and is not typically associated with hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia. When blood sugar levels are low, it can affect muscle function.
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