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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Measure the client's abdominal girth daily is correct. Ascites is characterized by fluid accumulation in the abdomen. Measuring abdominal girth regularly is important for monitoring changes in the amount of fluid retention and for assessing the progression of ascites. It is a standard nursing intervention for clients with this condition.

B. Keep the client's daily protein intake below 0.8 g/kg is incorrect. Protein intake should not be restricted to this extent. In fact, adequate protein is important for liver health and to prevent muscle wasting in clients with cirrhosis, unless there are complications such as hepatic encephalopathy.

C. Restrict the client's sodium intake to 3 g per day is incorrect. Sodium intake is typically restricted more severely for clients with ascites. The general recommendation is often less than 2 g per day to help prevent fluid retention and reduce the burden on the heart and kidneys.

D. Position the client supine with legs elevated is incorrect. While elevating the legs can help reduce edema in the legs, positioning the client supine does not provide the same benefit for ascites. Side-lying with legs elevated or sitting with the legs elevated may be more beneficial.

A. Patient care technician B. Psychologist C. Advanced practice nurse D. Social worker

Correct Answer is C

Explanation

A. Patient care technician is incorrect. A patient care technician (PCT) is typically responsible for assisting with basic care tasks, such as taking vital signs or helping with personal hygiene. A PCT is not qualified to assess or manage medication interactions.

B. Psychologist is incorrect. A psychologist specializes in mental health and behavior but does not have the expertise to manage or review medication interactions.

C. Advanced practice nurse is correct. An advanced practice nurse (APN), such as a nurse practitioner, has advanced education and training in pharmacology and the management of complex medication regimens. They can assess potential medication interactions and provide guidance on safe medication use.

D. Social worker is incorrect. While a social worker provides support in areas like coping with illness and accessing resources, they are not typically involved in managing or reviewing medication interactions.

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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?

Nursing Test Bank

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