In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?
Sucon the trachea.
Insert a urinary catheter.
Apply so restraints.
Insert a nasogastric tube.
The Correct Answer is A
Seizure precauons are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical acvity in the brain that can cause changes in behavior, movement, sensaon, or consciousness. Seizure precauons include providing a safe environment, monitoring the client's vital signs and neurological status, administering anconvulsant medicaons, and documenng the onset, duraon, and characteriscs of any seizure acvity³.
One of the potenal complicaons of a seizure is aspiraon, which is the inhalaon of foreign material into the lungs, such as saliva, vomit, or food. Aspiraon can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiraon, the praccal nurse (PN) should ensure the ready availability of equipment to perform suconing of the trachea, which is the tube that connects the mouth and nose to the lungs. Suconing of the trachea involves inserng a catheter through the nose or mouth into the trachea and applying negave pressure to remove any secreons or debris from the airway.
Therefore, opon A is the correct answer, while opons B, C, and D are incorrect.
Opon B is incorrect because inserng a urinary catheter is not related to seizure precauons or aspiraon prevenon.
Opon C is incorrect because applying so restraints may not be necessary or appropriate for a client who requires seizure precauons, as they may interfere with the natural movements of the seizure or cause injury to the client.
Opon D is incorrect because inserng a nasogastric tube is not related to seizure precauons or aspiraon prevenon.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Nurses performing duties outside of the nurses' typical job description is not a component of a disaster plan. Nurses should only perform tasks that are within their scope of practice, license, and competencE.
Choice B reason: A plan for comprehensive practice drills is a component of a disaster plan. Nurses should be involved in conducting regular drills to test and improve the preparedness and response of the staff and facility.
Choice C reason: Identification of resources to meet anticipated needs for food, water, and supplies is a component of a disaster plan. Nurses should be involved in assessing and securing the necessary resources to provide adequate care and support for the clients and staff during a disaster.
Choice D reason: An internal and external communication plan is a component of a disaster plan. Nurses should be involved in establishing and maintaining effective communication channels with other health care providers, agencies, authorities, media, and community during a disaster.
Choice E reason: Discharge all surgical clients who are one day or more post-op is not a component of a disaster plan. Nurses should not discharge clients without proper assessment, documentation, education, and follow-up arrangements.
Correct Answer is C
Explanation
Choice A reason: A negative-pressure isolation room is not appropriate for this client because it is used for clients who have airborne infections that can spread through small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. Scabies is a skin infection that is spread by direct contact with infested skin or clothinG.
Choice B reason: A positive-pressure isolation room is not appropriate for this client because it is used for clients who have compromised immune systems and need protection from environmental contaminants, such as bone marrow transplant recipients, burn victims, or organ transplant recipients. Scabies is not caused by environmental contaminants, but by parasitic mites that burrow under the skin.
Choice C reason: A private room is appropriate for this client because it prevents contact transmission of scabies to other clients or stafF. The client should also have dedicated equipment and linens, and wear gloves and gown when leaving the room. The room should be thoroughly cleaned and disinfected after the client's dischargE.
Choice D reason: A semi-private room with a client who has pediculosis capitis is not appropriate for this client because it increases the risk of cross-contamination between the two clients. Pediculosis capitis is a head lice infestation that can also be spread by direct contact with infested hair or personal items.
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