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
Related Questions
Correct Answer is B
Explanation
A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is A
Explanation
“Potassium 5.8 mEq/L” should be reported to the provider because it is higher than the normal range for potassium levels in the blood.
Normal potassium levels range from.6 to 5.2 millimoles per liter (mmol/L)1.
Choices B, C, and D are incorrect because sodium levels of 140 mEq/L, and magnesium levels of.9 mEq/L and calcium levels of 9.6 mg/dL are all within normal ranges and do not need to be reported to the provider.
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