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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Nausea:
Epinephrine is not typically used to treat nausea. Nausea is usually addressed with antiemetic medications. Epinephrine, an adrenergic agonist, works by stimulating the sympathetic nervous system to alleviate symptoms related to anaphylaxis, such as difficulty breathing or hypotension, but not nausea.
B) Hyperglycemia:
While epinephrine can increase blood sugar levels by stimulating the release of glucose from the liver, it is not used to treat hyperglycemia. Hyperglycemia management typically involves insulin or other medications designed to lower blood sugar, not epinephrine. Therefore, it is not an appropriate indication for this medication.
C) Hand tremors:
Hand tremors are a possible side effect of epinephrine due to its stimulatory effects on the sympathetic nervous system. However, tremors are not an indication for administering epinephrine. The purpose of an epinephrine auto-injector is not to treat tremors but rather to manage more serious conditions, like anaphylactic reactions.
D) Shortness of breath:
Epinephrine is commonly used in emergencies, such as anaphylactic reactions, to alleviate shortness of breath, which occurs due to bronchoconstriction. Epinephrine works by stimulating alpha and beta receptors, causing bronchodilation and improving airflow. This makes it effective in treating shortness of breath caused by allergic reactions or anaphylaxis.
Correct Answer is B
Explanation
A) Autonomy: Autonomy refers to the right of individuals to make their own choices and decisions. While the nurse’s actions may promote the client’s independence in the future, the nurse’s promise to walk with the client does not directly address or uphold the client’s autonomy. The nurse is offering support rather than encouraging the client to make independent decisions about their participation in the exercise.
B) Fidelity: Fidelity involves being faithful and keeping promises or commitments. In this scenario, the nurse promises to walk with the client in the courtyard each day, and this promise demonstrates the ethical principle of fidelity. The nurse is demonstrating trustworthiness and loyalty by committing to help the client overcome their anxiety and follow through with the daily exercise.
C) Justice: Justice is the ethical principle that focuses on fairness and equal treatment for all individuals. While justice is important in providing equal care to all clients, it is not the primary principle in this scenario. The nurse’s actions focus on meeting the specific needs of the individual client, which is more aligned with fidelity.
D) Nonmaleficence: Nonmaleficence means “do no harm.” While the nurse’s goal is to prevent harm by helping the client address their anxiety, the primary ethical principle at play here is fidelity, as the nurse is keeping their promise to provide consistent support. Nonmaleficence would be more relevant if the nurse were directly addressing potential harm or risk associated with the client’s situation, but the promise to walk with the client focuses more on the nurse’s commitment.
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