A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?
Oral suction equipment
Tongue depressor
Tracheostomy tray
Wrist restraints
The Correct Answer is A
A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Once my health care proxy is in place, I relinquish my right to make my own decisions" is incorrect. A health care proxy only comes into effect when the individual becomes incapacitated and unable to make decisions. Until then, the client retains the right to make their own decisions.
B. "My health care proxy designee is not able to sign a consent form on my behalf" is incorrect. The health care proxy designee is authorized to make decisions about medical treatment, which includes signing consent forms on the client’s behalf if the client is unable to do so.
C. "If I have a health care proxy, then I do not need to have a living will" is incorrect. A living will and a health care proxy are separate documents. A living will specify a person’s wishes regarding medical treatments in case they are unable to communicate, while a health care proxy designates someone to make decisions on their behalf. Both can be used together.
D. "I do not need to name a relative as my designee in my health care proxy" is correct. The designee does not have to be a relative. The client can choose anyone they trust to make healthcare decisions on their behalf when they are unable to do so.
Correct Answer is C
Explanation
A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.
B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.
C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.
D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.
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