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. Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.

B. Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination.

C. Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision.

D. Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.

A. BUN 20 mg/dL B. Platelet count 77,000/mm3 C. Hemoglobin 12 g/dL D. WBC count 18,000/mm3

Correct Answer is B

Explanation

A. BUN 20 mg/dL: This is not specific to HELLP syndrome. A BUN level of 20 mg/dL is within the normal range and does not indicate the presence of HELLP syndrome, which is associated with liver dysfunction and low platelet count.

B. Platelet count 77,000/mm3: This is correct. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) is characterized by a low platelet count, often less than 100,000/mm3, which is a critical indicator of this condition.

C. Hemoglobin 12 g/dL: This is a normal hemoglobin level and is not typically associated with HELLP syndrome, where hemolysis (destruction of red blood cells) can cause anemia, which would lower hemoglobin levels.

D. WBC count 18,000/mm3: While an elevated WBC count can indicate infection or inflammation, it is not specifically associated with HELLP syndrome. The hallmark features of HELLP syndrome are low platelets and liver enzyme elevation, not elevated WBC.

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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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