A nurse is planning care for a client who is undergoing alcohol withdrawal and is receiving diazepam. Which of the following interventions should the nurse include in the plan?

Administer the medication subcutaneously.

Initiate seizure precautions.

Administer the medication with an antacid.

Initiate contact precautions.

Answer and Explanation

The Correct Answer is B

A. Administer the medication subcutaneously – Diazepam should be given orally or intravenously in severe cases, not subcutaneously.

B. Initiate seizure precautions – This is the correct answer. Alcohol withdrawal can lead to seizures due to central nervous system hyperactivity. Diazepam, a benzodiazepine, is used to prevent seizures and manage withdrawal symptoms.

C. Administer the medication with an antacid – There is no need to administer diazepam with an antacid; doing so can interfere with absorption.

D. Initiate contact precautions – Alcohol withdrawal is not an infectious condition, so contact precautions are unnecessary.

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Correct Answer is A

Explanation

A. This is the correct answer. Gentle hand exercises, such as ball squeezing, help promote circulation and prevent lymphedema in the affected arm.

B. Avoiding use of the affected arm for eating is incorrect. Gradual movement is encouraged to prevent stiffness and maintain mobility.

C. Using deodorant under the affected arm is not recommended until healing is complete, as it may cause irritation or infection.

D. A bra with wire support should be avoided initially due to discomfort and potential interference with healing.

A. Place the client on an air mattress. B. Rewrap the bandage every 8 hr in a circular pattern. C. Turn the client every 4 hr while in bed. D. Instruct the client to use an overbed trapeze to move around in bed.

Correct Answer is D

Explanation

A. Place the client on an air mattress – While air mattresses help prevent pressure ulcers, they do not directly address mobility needs in the immediate postoperative period.

B. Rewrap the bandage every 8 hr in a circular pattern – The bandage should be reapplied more frequently (every 4–6 hr) using a figure-eight pattern to prevent restriction of circulation.

C. Turn the client every 4 hr while in bed – Clients should be turned at least every 2 hr to prevent pressure ulcers and improve circulation.

D. Instruct the client to use an overbed trapeze to move around in bed – This is the best intervention because it allows the client to reposition independently, reducing the risk of skin breakdown and enhancing mobility.

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A nurse is planning care for a client who is undergoing alcohol withdrawal and is receiving diazepam. Which of the following interventions should the nurse include in the plan?

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