A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
Tongue blade
NG tube
Oral airway
Wrist restraints
The Correct Answer is C
Choice A reason : A tongue blade should not be placed in the mouth during a seizure as it can cause injury or obstruct the airway.
Choice B reason: An NG tube, or nasogastric tube, is not typically required in the immediate management of seizures and should not be inserted during an active seizure due to the risk of injury.
Choice C reason: An oral airway may be used to maintain a patent airway during a postictal state if the client is unable to maintain their own airway.
Choice D reason: Wrist restraints are not routinely recommended for clients with seizure disorders as they can cause injury during a seizure. Safe environment and proper positioning are preferred to prevent injury.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Removing the weights before changing the client's bed linens is not recommended. The weights are an integral part of the traction system and removing them could disrupt the traction, potentially causing harm or discomfort to the client. The weights must be maintained to ensure the effectiveness of the skeletal traction.
Choice B reason: Instructing the client to use their elbows to reposition themselves could be helpful, but it is not the primary action the nurse should take. While maintaining some degree of mobility is important, the nurse must ensure that the traction setup is not disturbed during any movement.
Choice C reason: Checking pressure points every 12 hours is important to prevent skin breakdown and ulcers, especially in immobilized patients. However, this is a routine action and not specific to the care of a client with skeletal traction. The nurse should check pressure points more frequently, considering the increased risk of pressure sores in immobilized patients.
Choice D reason: Providing the client with a trapeze bar is the correct action. A trapeze bar allows the client to independently reposition themselves while maintaining the integrity of the traction. It helps the client to move and shift weight, which can aid in preventing complications such as pressure ulcers and muscle atrophy. It also gives the client a sense of control and independence in their care.
Correct Answer is A
Explanation
Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.

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