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 B
Explanation
Choice A reason: Performing carotid massage is not an appropriate action for the nurse to take because it can worsen the client's condition by decreasing the blood flow to the brain, causing further ischemia or hemorrhagE. Carotid massage is a technique that involves applying pressure to the carotid artery to slow down the heart rate, which can be dangerous for clients who have a strokE.
Choice B reason: Calling for help is an appropriate action for the nurse to take because it can initiate the rapid response team and activate the stroke protocol, which can improve the client's outcome and survival. The nurse should also assess the client's vital signs, neurological status, and time of symptom onset, and report them to the health care provider.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for the nurse to take because it can increase the risk of aspiration and pneumonia, which can complicate the client's recovery and prognosis. The nurse should avoid giving anything by mouth to the client until their swallowing ability is evaluated by a speech therapist or a swallow study.
Choice D reason: Administering thrombolytics is not an appropriate action for the nurse to take because it requires a physician's order and confirmation of the type and cause of stroke by a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. Thrombolytics are drugs that dissolve blood clots and restore blood flow, which can be beneficial for clients who have ischemic stroke, but harmful for clients who have hemorrhagic strokE.
Correct Answer is B
Explanation
Choice A reason: Developing a survey on teen pregnancies is not an appropriate action by the nurse because it does not address the issue of influenza A outbreak in the school, which can affect students of any age or gender.
Choice B reason: Holding a focus group to discuss immunizations is an appropriate action by the nurse because it can educate and inform parents and students about the benefits and risks of influenza vaccination, as well as encourage them to get vaccinated before or during flu season.
Choice C reason: Running a mandatory flu clinic is not an appropriate action by the nurse because it can violate the rights and autonomy of parents and students who may have medical or personal reasons for refusing influenza vaccination, as well as create resentment and resistance among them.
Choice D reason: Closing the school for 6 weeks is not an appropriate action by the nurse because it can disrupt the education and socialization of students, as well as cause economic and logistic problems for parents and teachers. The recommended duration of school closure for influenza A outbreak is 5 to 7 days, which is the typical incubation period of the virus.
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