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

Choice A rationale:

(Correct Choice) Checking the expiration date on the safety inspection sticker of the pump is essential to ensure the equipment is functioning properly and safely. Using expired equipment can compromise the client's safety and the effectiveness of the treatment.

Choice B rationale:

Verifying that the extension cord for the pump is ungrounded is important for electrical safety. However, it is not the nurse's responsibility to do this. This action should be performed by a qualified electrician or facility maintenance personnel.

Choice C rationale:

Reporting the pump with a frayed cord is essential. However, it is not safe to proceed with the infusion in this situation. Using damaged equipment can lead to electrical hazards and compromise the client's safety.

Choice D rationale:

Obtaining a surge protector is important for protecting the pump and other electrical appliances from power surges. While this is a good practice, it is not the first action the nurse should take when preparing to initiate intravenous fluids.

A. Use a 12-point font when printing written materials for the client. B. Present the information to the client using abstract concepts. C. Connect new information with the client's past experiences. D. Speak loudly when addressing the client.

Correct Answer is C

Explanation

Choice A rationale:

Using a 12-point font when printing written materials is helpful for readability, especially for individuals with visual impairments. However, this action alone does not necessarily promote meaningful learning. The content and presentation style are equally important.

Choice B rationale:

Presenting information using abstract concepts can be confusing, especially for older adults. Using concrete examples and simple language facilitates better understanding. Abstract concepts are more challenging to grasp, especially for individuals who might be experiencing cognitive decline.

Choice C rationale:

Connecting new information with the client's past experiences enhances learning and retention. Relating new knowledge to familiar situations or memories helps create cognitive associations, making it easier for the client to understand and remember the information. This technique is particularly effective in promoting learning among older adults.

Choice D rationale:

Speaking loudly when addressing the client is unnecessary and can be perceived as rude or patronizing. Clear and audible speech is essential, but shouting or raising the volume excessively is not respectful and does not enhance the learning experience.

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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?

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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?