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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The client reports joint pain in the knee and wrist with a history of gout in the family. The elevated uric acid level (7.2 mg/dL) supports a diagnosis of gout, a condition caused by uric acid crystal deposition in the joints. The negative ANA and normal ESR make inflammatory autoimmune conditions like rheumatoid arthritis and systemic lupus erythematosus unlikely.
Actions to Take:
Instruct the client to avoid foods high in purines.
Purine-rich foods (e.g., red meat, shellfish, organ meats) contribute to increased uric acid production, exacerbating gout symptoms. Dietary modifications can help reduce flare-ups and long-term complications.
Instruct the client to apply topical analgesics.
Topical analgesics can provide localized pain relief and reduce discomfort in affected joints. They serve as an adjunct to systemic medications in managing acute symptoms.
Parameters to Monitor:
Uric acid levels.
Monitoring uric acid levels helps assess the effectiveness of dietary changes and medications in preventing flare-ups and reducing joint damage.
Joint deformities.
Chronic gout can lead to joint destruction and tophi formation, so assessing for deformities helps track disease progression and the need for further interventions.
Correct Answer is ["30"]
Explanation
To calculate the drip rate, follow these steps:
- The client needs to receive 120 mL of lactated Ringer's over 1 hour (60 minutes).
- The IV tubing has a drip factor of 15 drops per mL (15 gtt/mL).
- Multiply the total volume (120 mL) by the drip factor (15 gtt/mL), which gives 1,800 drops.
- Divide this by the total time in minutes (60 minutes).
1,800 drops ÷ 60 minutes = 30 drops per minute (30 gtt/min)
Final Answer:
30 gtt/min
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