A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure.
Which of the following actions should the nurse take following the seizure.

Choice A rationale

Using clean technique for invasive procedures in a neutropenic client is insufficient. Neutropenia is a severe reduction in neutrophils, a key component of the immune system, leaving the client highly susceptible to infection. Aseptic or sterile technique, rather than clean technique, is necessary for all invasive procedures to prevent the introduction of pathogens. This includes strict hand hygiene, sterile gloves, and sterile fields to minimize infection risk.

Choice B rationale

Allowing healthy children to visit is a dangerous practice for a neutropenic client. Children, even those appearing healthy, can carry and transmit pathogens like viruses and bacteria that their developing immune systems can easily fight off. In a client with neutropenia, however, these common microorganisms can cause severe, life-threatening infections due to the lack of an adequate immune response. Therefore, visitors must be carefully screened.

Choice C rationale

Cleaning the client's room every 2 days is an inadequate frequency for a neutropenic client. An environment with reduced pathogen exposure is crucial for these immunocompromised clients. The room should be cleaned daily to minimize the accumulation of dust, dirt, and microorganisms. All surfaces, including floors, tables, and equipment, must be disinfected to reduce the risk of nosocomial infections and maintain a sterile environment.

Choice D rationale

Neutropenia impairs the body's ability to mount a fever response to infection. Therefore, a low-grade temperature elevation may be the only sign of a serious infection. Monitoring the client's temperature frequently, typically every 4 hours, is a critical nursing intervention. Early detection of a fever, even a slight one, allows for prompt initiation of antibiotics and other treatments, significantly improving the client's prognosis and preventing a potential septic shock. *.

Choice A rationale

Losartan is an angiotensin II receptor blocker (ARB) which works by preventing angiotensin II from binding to its receptors in vascular smooth muscle, thereby causing vasodilation and lowering blood pressure. Hypertension is the condition losartan is prescribed to treat, not an adverse effect, because its mechanism directly counteracts the vasoconstrictive effects of angiotensin II. The intended therapeutic effect is a reduction in systemic vascular resistance and blood pressure.

Choice B rationale

Double vision, also known as diplopia, is not a recognized common or significant adverse effect of losartan. The mechanism of action of losartan primarily targets the renin-angiotensin-aldosterone system (RAAS), influencing blood pressure regulation and fluid balance, not directly affecting the central nervous system or ocular motor function. This symptom would be more indicative of neurological or ophthalmological issues unrelated to the medication's primary action.

Choice C rationale

Dizziness is a common adverse effect of losartan. This is a direct consequence of its therapeutic action, which is to lower blood pressure. The resulting vasodilation and reduced blood pressure can lead to orthostatic hypotension, causing feelings of lightheadedness or dizziness, especially when a person changes positions, like standing up. The brain's reduced perfusion pressure triggers this sensation as a physiological response.

Choice D rationale

Hyperactivity is not an expected adverse effect of losartan. The medication primarily affects the cardiovascular system by modulating the RAAS to lower blood pressure. It does not have known stimulant properties that would lead to increased energy, restlessness, or hyperactivity. Such a finding would likely be attributed to other factors or a different underlying condition, not the pharmacological action of this medication. *.