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:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

A. Slowly instill 400 to 500 mL of the prescribed solution. B. Clamp the drainage tubing distal to the injection port. C. Use a syringe with a 19-gauge needle. D. Withdraw the irrigation solution into the syringe.

Correct Answer is A

Explanation

Choice A rationale:

During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.

Choice B rationale:

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Choice C rationale:

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Choice D rationale:

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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