A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?

Pad the upper two side rails of the client's bed.

Maintain peripheral IV access.

Teach assistive personnel how to apply restraints.

Keep a padded tongue blade at the client's bedside.

Answer and Explanation

The Correct Answer is A

A)   Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B)   Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C)   Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D)   Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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Correct Answer is C

Explanation

A) This is not a standard intervention for bladder spasms post-TURP.

B) Securing the urinary catheter to the abdomen does not address the immediate issue of potential catheter blockage.
C) Performing an intermittent bladder irrigation using sodium chloride is appropriate in this case. This is because bladder spasms and a scant amount of fluid in the urinary drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation can help to remove any clots or debris that may be causing the blockage.
D) Encouraging the client to urinate is not applicable as the client cannot urinate normally due to the surgery.

A. Slow infusion rate and contact the provider. B. Lower the head of the bed to semi-Fowler's. C. Administer prescribed corticosteroids. D. Change infusion to lactated Ringer's and maintain rate.

Correct Answer is A

Explanation

A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

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Correct Answer is C

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?