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 D
Explanation
Choice A rationale:
Taking antibiotics when having a virus is not a correct understanding of infection prevention. Antibiotics are ineffective against viruses and should only be used for bacterial infections under the guidance of a healthcare provider. This statement indicates a misunderstanding of infection prevention.
Choice B rationale:
Washing hands for at least 20 seconds with soap and water is the recommended practice for infection prevention. Washing hands for 10 seconds may not be sufficient to remove all germs effectively. This statement does not demonstrate a proper understanding of hand hygiene.
Choice C rationale:
Cleaning a cat's litter box during pregnancy is not recommended due to the risk of contracting toxoplasmosis, a parasitic infection that can harm the fetus. Pregnant individuals should avoid handling cat litter to prevent exposure to this infection. This statement indicates a lack of awareness regarding infection prevention during pregnancy.
Choice D rationale:
Waiting 5 days after the chickenpox sores have crusted before visiting a person with chickenpox demonstrates an understanding of infection prevention. Chickenpox is highly contagious, and individuals should avoid close contact until the sores have fully healed and crusted over. This statement reflects appropriate knowledge about preventing the spread of contagious diseases during pregnancy.
Correct Answer is ["A","C"]
Explanation
The correct answers are Choices A and C.
Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.
Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.
Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.
Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.
Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.
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