A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

Suctioning device

Bite block

Vest restraint

Padded tongue blade

Answer and Explanation

The Correct Answer is A

A. Suctioning device – Correct. A suctioning device is essential to clear the airway in case of excessive secretions during or after a seizure.

B. Bite block – Incorrect. Bite blocks are not used during seizures as they can cause injury. Nothing should be placed in the client’s mouth during a seizure.

C. Vest restraint – Incorrect. Restraints should not be used on clients with seizure disorders as they can cause injury.

D. Padded tongue blade – Incorrect. Tongue blades should never be inserted into the mouth of a seizing client due to the risk of airway obstruction and oral trauma.

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Correct Answer is C

Explanation

A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.

B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.

C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.

D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.

A. "You should wear a snug-fitting bra continuously for 72 hours." B. "You should apply moist heat to your breasts four times per day." C. "You should limit your fluid intake to 1 liter per day." D. "You should manually express milk when engorgement occurs."

Correct Answer is A

Explanation

A. This is the correct answer. A snug-fitting bra helps suppress lactation and provides support to relieve discomfort. It should be worn continuously, even while sleeping, for 72 hours.

B. Moist heat stimulates milk production and should be avoided. Instead, cold compresses can help reduce swelling.

C. Fluid restriction is not necessary and could lead to dehydration.

D. Manually expressing milk will encourage continued milk production rather than suppressing lactation.

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A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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