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 D
Explanation
Choice A rationale
Administering a 500 mL lactated Ringer’s IV bolus is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice B rationale
Documenting urinary output is important, but it is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice C rationale
Replacing the surgical dressing is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice D rationale
Notifying the healthcare provider is the correct action. Persistent vaginal bleeding after a cesarean birth could indicate a postpartum hemorrhage, which is a medical emergency
Correct Answer is C
Explanation
Choice A rationale
Instructing the client to avoid urinary elimination until after administration is not necessary. The administration of dinoprostone does not interfere with the client’s ability to urinate.
Therefore, this action is not required.
Choice B rationale
Placing the client in a semi-Fowler’s position for 1 hr after administration is not a necessary action. While positioning can be important in certain medical procedures, there is no specific requirement for a semi-Fowler’s position in the administration of dinoprostone.
Choice C rationale
Verifying that informed consent is obtained prior to administration is a crucial step in any medical procedure, including the administration of dinoprostone. Informed consent ensures that the client is aware of the procedure, its purpose, and any potential risks or benefits. It is a legal and ethical requirement.
Choice D rationale
Allowing the medication to reach room temperature prior to administration is not a necessary action. There is no specific requirement for dinoprostone to be at room temperature before administration.
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