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 C

Explanation

Choice A rationale:

Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.

Choice B rationale:

Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.

Choice C rationale:

Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.

Choice D rationale:

Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.

A. Use a 5-mL syringe to flush the catheter. B. Change the site dressing and stabilization device every 24 hr. C. Expect blood to appear in the catheter lumen after flushing. D. Use chlorhexidine solution to clean the catheter.

Correct Answer is D

Explanation

Choice A rationale:

Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.

Choice B rationale:

Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.

Choice C rationale:

Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.

Choice D rationale:

This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.

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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

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Correct Answer is D

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