A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for the client?

NG tube

Tongue blade

Suction machine

Syringe containing lorazepam

Answer and Explanation

The Correct Answer is C

A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure disorder unless they have specific feeding or aspiration concerns that require tube feeding. During a seizure, the priority is to ensure airway clearance and prevent injury, not necessarily to provide nutrition through an NG tube.

B) Tongue blade: It is a common myth that tongue blades should be used to prevent a client from biting their tongue during a seizure. However, using a tongue blade can be dangerous as it can cause injury to the mouth or teeth, or even cause choking. The nurse should never attempt to place anything in the client's mouth during a seizure.

C) Suction machine: A suction machine is essential for maintaining airway patency during or after a seizure. Clients with seizure disorders may be at risk for aspiration, and the suction machine can be used to clear secretions from the mouth to prevent choking or aspiration pneumonia. This is the most appropriate supply to place at the bedside.

D) Syringe containing lorazepam: While lorazepam (a benzodiazepine) is sometimes used for acute seizure management, it is not a routine item to have immediately at the bedside unless specifically ordered for emergency seizure intervention. The nurse should follow protocol and administer medications as prescribed, but a syringe of lorazepam is not typically pre-placed at the bedside.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) You can splint the incision with a pillow when changing position: Splinting the incision with a pillow is an excellent nonpharmacological method to manage pain during position changes after a cesarean section. The pillow helps provide support to the incision site, reduces strain on the abdominal muscles, and minimizes discomfort when the client moves. This is a safe and effective intervention to help with pain management.

B) You should change position as little as possible: While minimizing movement might seem like a way to prevent pain, it can lead to complications like muscle stiffness, poor circulation, and respiratory issues. It’s important for clients to change positions to promote comfort, circulation, and lung expansion, but they should do so with support to manage pain effectively.

C) You should use patterned paced breathing when changing positions: Patterned paced breathing is a helpful relaxation technique that can be used in various situations, including labor and delivery. However, it is not the most appropriate response in this context, as the client’s pain is more related to physical discomfort from the incision, and physical support (like splinting the incision) would be more effective in managing this type of pain.

D) You can apply counterpressure to your back with each position change: While counterpressure can be beneficial for back pain during labor, it is not the most relevant technique for managing pain after a cesarean section, where the pain is related to the abdominal incision site. Splinting the incision provides more targeted support for post-cesarean discomfort.

A. Assist the client with range-of-motion exercises of the hands. B. Determine the circulation status of the affected extremities every hr. C. Instruct the client's family about the purpose of mitten restraints. D. Evaluate the need for the client to remain in mitten restraints

Correct Answer is A

Explanation

A) Assist the client with range-of-motion exercises of the hands:
This task is appropriate for the assistive personnel (AP) as it is a routine, non-invasive intervention that can help maintain mobility and prevent contractures in the hands. The AP can assist with range-of-motion exercises, following proper technique, and reporting any abnormalities to the nurse. This falls within the AP's scope of practice and can be delegated to them effectively.

B) Determine the circulation status of the affected extremities every hr:
Assessing circulation is a nursing responsibility and requires clinical judgment to identify signs of impaired circulation, such as color changes, pulse, or temperature of the skin. This task cannot be delegated to an AP, as it requires a nurse’s skill to interpret findings and take appropriate action.

C) Instruct the client's family about the purpose of mitten restraints:
Educating the client's family about the use of mitten restraints is a responsibility of the nurse, not the AP. This involves assessing the family’s understanding, providing relevant information, and answering any questions they may have. Only licensed healthcare professionals are responsible for providing education about the purpose and use of restraints.

D) Evaluate the need for the client to remain in mitten restraints:
Evaluating the necessity of restraints involves assessing the client's condition, safety, and overall care needs. This requires critical thinking and professional judgment and should be performed by the nurse, not the AP. The nurse must determine if the restraints continue to be necessary or if they can be removed, ensuring the client’s safety and dignity.

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A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for the client?

Nursing Test Bank

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Explanation

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Explanation

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