A nurse is implementing seizure precautions for a client who has a seizure disorder.
Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.).
Limb restraints.
Blood glucose monitor.
Oral airway.
Supplemental oxygen supplies.
Oral suction equipment.
Correct Answer : C,D,E
An oral airway can help maintain an open airway during a seizure.
Supplemental oxygen supplies can be used to provide oxygen if the client’s breathing is compromised.
Oral suction equipment can be used to clear secretions from the client’s mouth and prevent aspiration.
Limb restraints: Restraints should not be used during a seizure as they can cause injury.
Blood glucose monitor: While it is important to monitor blood glucose levels in clients with seizures, it is not a priority during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
According to a study published on PubMed, it is appropriate to change alimentation tubes and feeding bags every 72 hours rather than every 24 hours.
Choice B, Aspirate residual volume every 4 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.
Choice C, Flush the tubing with 10 mL of water every 2 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.
Choice D, Heat the formula to 40.5° C (105° F), is not necessary for continuous enteral feedings through a gastrostomy tube.
Correct Answer is A
Explanation
Secure the tracheostomy ties to allow one finger to fit snugly underneath. This is important to ensure that the tracheostomy tube is secure and in place.
Choice B is wrong because normal saline is not typically used to cleanse the skin around the stoma.
Choice C is wrong because soaking the outer cannula in warm, soapy tap water is not a recommended method of cleaning.
Choice D is wrong because a cotton tip applicator should not be used to clean inside the inner cannula.
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