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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) "My child has some swelling around her eyelids and mouth."

In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.

The other findings, while important, are not as immediately concerning:

B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.

C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.

D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.

A. Decreased BUN level B. Decreased hemoglobin level C. Increased urinary output D. Increased weight of 0.91 kg (2 lb)

Correct Answer is C

Explanation

The correct answer is C. Increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin level may indicate anemia or bleeding. Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hr ago. Which of the following findings reported by the parent is the nurse's priority?

Correct Answer is A

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A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is C

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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?