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.

Answer and Explanation

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.

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Correct Answer is ["B","E"]

Explanation

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse because it can expose more people to the chemical spill and worsen their condition. The triage nurse should stop the triage process and alert the emergency department staff about the potential contamination.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse because it can prevent further exposure and harm to other clients, staff, and visitors. The emergency department should be cleared and sealed until it is safe to re-enter.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse because it can contaminate the room and its equipment, as well as pose a risk to anyone who enters or leaves the room. The client should be isolated in a designated area for decontamination.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse because it can delay the treatment and increase the absorption of the chemical into the body. The client should be treated as soon as possible after decontamination.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse because it can remove or neutralize the chemical from their skin, clothing, and equipment, as well as reduce their symptoms and complications. The client and EMS crew should be directed to a designated area for decontamination.

A. Deliver a clean voided urine specimen to the laboratory. B. Feed a client who has bilateral casts due to upper arm fractures. C. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. D. Obtain an extra box of tissues for a client who is concerned about running out of them.

Correct Answer is C

Explanation

Choice A reason: Delivering a clean voided urine specimen to the laboratory is not the first task that the AP should complete because it is not urgent or time-sensitivE. The specimen can be stored in a refrigerator or on ice until it is delivereD.

Choice B reason: Feeding a client who has bilateral casts due to upper arm fractures is not the first task that the AP should complete because it is not critical or life-threateninG. The client can wait until after breakfast to receive assistance with feedinG.

Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast is the first task that the AP should complete because it is essential and priority. The client needs to have their blood glucose level checked before receiving insulin to prevent hypoglycemia or hyperglycemiA.

Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is not the first task that the AP should complete because it is not important or necessary. The client can use other alternatives such as paper towels or napkins until they get more tissues.

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In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?

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