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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Decreasing bright lights is not the first action that the nurse should perform because it does not address the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Decreasing bright lights can help reduce photophobia and headache, but it is not an urgent intervention.
Choice B reason: Initiating IV access is not the first action that the nurse should perform because it does not address the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Initiating IV access can facilitate fluid and medication administration, but it is not an immediate intervention.
Choice C reason: Administering antibiotics is not the first action that the nurse should perform because it requires a physician's order and confirmation of the diagnosis and causative organism by laboratory tests such as blood culture or cerebrospinal fluid (CSF) analysis. Administering antibiotics can treat bacterial meningitis, but it is not a priority intervention.
Choice D reason: Implementing droplet precautions is the first action that the nurse should perform because it addresses the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Implementing droplet precautions can prevent transmission of meningitis to other clients or staff, as meningitis can be spread by respiratory droplets from coughing, sneezing, or talkinG.
Correct Answer is C
Explanation
When a client reports experiencing numbness and ngling in the extremies, it is crucial for the praccal nurse (PN) to prioritise reporting the client's electrolyte levels to the healthcare provider. Electrolytes are essential minerals that help maintain the balance of fluids in the body and enable proper nerve and muscle function. Imbalances in electrolyte levels can lead to neurological symptoms, including numbness and ngling.
Opons a, b, and d are not the correct priories to report in this situation:
a) Hematocrit: Hematocrit measures the proportion of red blood cells in the blood. While abnormalies in hematocrit can indicate certain conditions, such as anaemia, it is not directly associated with numbness and ngling in the extremes.
b) Albumin and protein levels: Albumin and protein levels are important for assessing nutritional status and liver function. While low levels of protein can contribute to various health issues, they are not the primary concern when a client experiences numbness and ngling in the extremities.
d) White blood cell count (WBC): WBC count is used to evaluate the immune system's response to infection or inflammation. While infections or inflammatory conditions can cause neurological symptoms, such as ngling, it is not the primary concern in this specific case of numbness and ngling.
Therefore, the most appropriate laboratory value to prioritise reporting in this scenario is the client's electrolyte levels, as imbalances can directly contribute to the reported symptoms and may require prompt intervention.
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