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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.
B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.
C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.
Correct Answer is A
Explanation
A. Place a pillow under the child's head: This is correct. The nurse should place a soft object, such as a pillow or folded blanket, under the child’s head to prevent head injury during a seizure. It is important to protect the patient from harm without interfering with the seizure.
B. Turn the child onto their back: This is not advisable during a seizure. The child should remain in a safe position, preferably on their side to help maintain the airway and prevent aspiration. Turning onto their back is not a first-line intervention.
C. Place a padded tongue blade in the child's mouth: This is incorrect. A padded tongue blade should never be inserted into the mouth during a seizure, as it can cause dental or oral injury, and may lead to aspiration or choking.
D. Restrain the child's upper extremities: Restraining the child is not recommended during a seizure. The child should not be physically restrained during the event, as this could cause injury or increase the risk of aspiration. The nurse should focus on providing safety and not interfering with the natural movements during a seizure.
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