A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure.
Which of the following interventions should the nurse include in the plan of care?
Provide a tracheostomy tray at the bedside.
Place the client in a supine position.
Place a plastic tongue depressor at the client's bedside.
Insert an IV saline lock.
The Correct Answer is D
The correct answer is choice D: Insert an IV saline lock.
Choice D rationale: Inserting an IV saline lock is an appropriate nursing intervention for a client with a tonic-clonic seizure. This allows for quick access to administer intravenous medications, such as anticonvulsants, in case the client experiences another seizure.
Choice A rationale: Providing a tracheostomy tray at the bedside is not necessary for seizure precautions. While maintaining a patent airway is essential during a seizure, it can typically be managed with proper positioning and suctioning if necessary.
Choice B rationale: Placing the client in a supine position is not recommended for seizure precautions. Instead, the client should be placed in a semi-prone or lateral position to promote drainage of secretions and prevent aspiration.
Choice C rationale: Placing a plastic tongue depressor at the client's bedside is not an appropriate intervention. Attempting to insert an object into the client's mouth during a seizure can cause injury and is not recommended.
In summary, the nurse should include inserting an IV saline lock as part of the plan of care for a client who has experienced a tonic-clonic seizure. This will allow for rapid administration of medications, if necessary, while prioritizing client safety and adhering to seizure precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
After a total gastrectomy, the client lacks the intrinsic factor necessary for the absorption of vitamin B12 in the terminal ileum. Therefore, vitamin B12 supplementation is essential to prevent pernicious anemia, a condition caused by vitamin B12 deficiency. The absence of intrinsic factor hinders the absorption of vitamin B12 from dietary sources, making it necessary to provide this vitamin through injections or high-dose oral supplements. Vitamin B12 supplementation is a standard practice following a total gastrectomy.
Choice B rationale:
Ranitidine is a histamine-2 (H2) receptor antagonist used to reduce stomach acid production. It is not directly related to vitamin B12 deficiency and is not typically prescribed following a total gastrectomy. Vitamin B12 supplementation, on the other hand, addresses the specific deficiency caused by the absence of intrinsic factor.
Choice C rationale:
Vitamin K is essential for blood clotting and bone health. However, it is not the primary concern following a total gastrectomy. Vitamin B12 deficiency leading to pernicious anemia is the major focus of post-gastrectomy supplementation. While vitamin K may be important for overall health, it is not the immediate priority in this scenario.
Choice D rationale:
Metoclopramide is a medication used to treat gastrointestinal disorders, including gastroparesis and gastroesophageal reflux disease (GERD). It does not directly address the vitamin B12 deficiency resulting from the absence of intrinsic factor. Vitamin B12 supplementation is specifically indicated to prevent pernicious anemia in this context.
Correct Answer is C
Explanation
The correct answer isChoice C.
Choice A rationale:
Encouraging the client to drink low-protein supplements is not the best action. Protein is essential for tissue repair and healing, especially when the body is under stress, such as during radiation therapy. Therefore, it would be more beneficial to encourage high-protein foods and supplements.
Choice B rationale:
Serving the client’s largest meal in the evening is not the most effective strategy. Radiation therapy can cause nausea and vomiting, which are often worse later in the day. Therefore, it might be more beneficial to serve a larger meal earlier in the day when the client is more likely to tolerate it.
Choice C rationale:
Providing the client with cold foods rather than hot foods is the correct action. Hot foods can often exacerbate feelings of nausea, which are common side effects of radiation therapy.Cold foods are generally better tolerated.
Choice D rationale:
Telling the client to drink two glasses of water with meals is not the best advice. While hydration is important, drinking large amounts of fluid with meals can contribute to early satiety, which can further decrease the client’s food intake. It might be more beneficial to encourage the client to drink fluids between meals.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.