A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care?

Plan to insert an oral airway if seizure activity begins.

Plan to administer pain medication after the seizure.

Pad the side rails of the client's bed with blankets.

Place the client in a supine position during a seizure.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Planning to insert an oral airway if seizure activity begins is not a suitable intervention for a client with a history of seizures. During a seizure, it's essential to protect the client from injury by preventing them from aspirating secretions or foreign objects. However, inserting an oral airway during an active seizure can be dangerous and lead to injury.

Choice B rationale:

Administering pain medication after the seizure is not a priority intervention. While some clients may experience muscle soreness or discomfort following a seizure, the primary focus during and immediately after a seizure is ensuring the client's safety and preventing injury. Pain medication can be considered later if necessary.

Choice C rationale:

The correct choice is to pad the side rails of the client's bed with blankets. This intervention aims to prevent injury if the client experiences a seizure and comes into contact with the bed rails. Padding the side rails can reduce the risk of trauma and minimize the potential for harm during a seizure episode.

Choice D rationale:

Placing the client in a supine position during a seizure is not recommended. It's important to position the client on their side (lateral recumbent position) during a seizure to allow any oral secretions or vomit to drain from the mouth, reducing the risk of aspiration. Placing the client supine could obstruct the airway and increase the risk of aspiration.

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Correct Answer is B

Explanation

Choice A rationale:

The family member understanding that the nurse can adjust the mother's pain medication as needed indicates an understanding of the nurse's role in managing the patient's symptoms. However, this statement does not demonstrate an understanding of end-of-life care as a holistic process involving various aspects beyond pain management.

Choice B rationale:

This choice reflects a comprehensive understanding of end-of-life care. The family's responsibility to obtain support services shows awareness of the need for a multidisciplinary approach to address physical, emotional, and practical needs during this process. End-of-life care is a collaborative effort, and this choice accurately acknowledges the role of the family in coordinating necessary services.

Choice C rationale:

The statement about prolonging the patient's life through services reflects a misconception about end-of-life care. The focus of end-of-life care is on improving the quality of life and managing symptoms rather than attempting to extend life. This choice suggests a lack of understanding about the terminal nature of the illness.

Choice D rationale:

Believing that the doctor will make all decisions about the patient's care might indicate a lack of involvement or shared decision-making in the care process. End-of-life care often involves discussions among the medical team, patients, and their families to ensure that the patient's wishes and preferences are respected.

A. Measure the amount of aspirate in the NG tube. B. Flush the tube with 50 mL of tap water. C. Examine the color of aspirated secretions. D. Measure the pH of the client's aspirate. E. Obtain an x-ray of the client's chest and abdomen.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.

Choice B rationale:

Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.

Choice C rationale:

Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.

Choice D rationale:

Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.

Choice E rationale:

Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.

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A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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