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
Correct Answer is B
Explanation
The correct answer is: b. Determine goals of the day.
Choice A: Schedule daily activities.
Rationale: Scheduling daily activities is crucial for time management but should follow establishing goals. The nurse must first determine the priorities and objectives for the day before organizing the tasks.
Choice B: Determine goals of the day.
Rationale: Identifying the goals of the day is the first step in effective time management for a nurse. This enables the nurse to prioritize patient care and other responsibilities, ensuring that essential tasks are accomplished and patient needs are met. Goals can include completing assessments, administering medications, and attending to patient concerns.
Choice C: Delegate tasks to the AP.
Rationale: Delegating tasks is vital in managing time and resources, but it should occur after the goals and priorities are determined. The nurse must first know which tasks need to be completed before assigning responsibilities to the LPN and AP.
Choice D: Develop an hourly time frame for tasks.
Rationale: Creating a timeline for tasks is essential for time management but should be done after setting goals and prioritizing tasks. This will enable the nurse to allocate an appropriate amount of time for each task and help ensure that all necessary tasks are completed within the shift.
In conclusion, by first determining the goals of the day, the nurse can effectively manage time and ensure that all essential tasks are completed. Prioritizing patient care and other responsibilities will enable the nurse to collaborate effectively with the LPN and AP in delegating tasks and scheduling activities.
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