A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?
Dim the lights in the client's room.
Ensure the call button is within the client's reach.
Pad the side rails of the client's bed.
Place suction equipment at the client's bedside.
The Correct Answer is C
Choice A rationale:
Dimming the lights in the client’s room can help create a calming environment but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice B rationale:
Ensuring the call button is within the client’s reach is important for patient safety and communication, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice C rationale:
Padding the side rails of the client’s bed is the priority when implementing seizure precautions for a client with preeclampsia. This is to protect the client from injury during a seizure.
Choice D rationale:
Placing suction equipment at the client’s bedside is important for maintaining airway patency after a seizure, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.
Correct Answer is D
Explanation
Choice A rationale:
Droplet precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). This is not the case with Clostridium difficile.
Choice B rationale:
Airborne precautions are used for diseases or germs that are spread through the air (examples: tuberculosis, measles, chickenpox). This is not the case with Clostridium difficile.
Choice C rationale:
A protective environment is a room designed to reduce the risk of infections from airborne, droplet, and contact transmissions. It’s typically for patients who have undergone stem cell transplants. This is not necessary for Clostridium difficile.
Choice D rationale:
Contact precautions are used for diseases or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds). Clostridium difficile is spread via contact, hence contact precautions are appropriate.
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