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. Review the need for the UAP to wear a face mask while in close contact with the client. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Assign the UAP to provide care for another client and assume full care of the client. D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.

Choice B rationale:

A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.

Choice C rationale:

Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.

Choice D rationale:

Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

Correct Answer is A

Explanation

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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?