In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?
Suction the trachea.
Insert a nasogastric tube.
Insert a urinary catheter.
Apply soft restraints.
The Correct Answer is A
Suction the trachea.
Choice A rationale:
The practical nurse (PN) should ensure the ready availability of equipment to perform tracheal suctioning for a client who requires seizure precautions. Seizures can sometimes cause excessive salivation or even vomiting, which may lead to the obstruction of the airway. Suctioning the trachea helps in quickly clearing any secretions or vomitus from the airway, preventing potential respiratory compromise and ensuring the client's airway remains patent.
Choice B rationale:
Inserting a nasogastric tube is not directly related to seizure precautions. Nasogastric tubes are used for various purposes, such as decompression of the stomach, feeding, or administering medications. While it might be necessary in specific situations, it is not a priority when caring for a client on seizure precautions.
Choice C rationale:
Inserting a urinary catheter is also not directly related to seizure precautions. It is typically done for clients who have difficulty urinating on their own or for precise monitoring of urine output. Seizure precautions focus on the client's airway and safety during a seizure episode.
Choice D rationale:
Applying soft restraints is generally not recommended for clients on seizure precautions. Restraints should only be used as a last resort for clients who pose a risk to themselves or others during a seizure. The primary goal is to provide a safe environment and prevent injuries without restraining the client unless absolutely necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Observe how UAP obtains temperatures.
Choice A rationale:
The PN should first observe how the unlicensed assistive personnel (UAP) obtains temperatures using a tympanic thermometer. This step is essential to determine if there is an error in the technique or if the thermometer is malfunctioning. Correct technique and proper use of equipment are crucial to obtaining accurate and reliable temperature readings.
Choice B rationale:
While returning the thermometer for recalibration might be necessary if the thermometer is indeed faulty, it should not be the first action the PN takes. Observing the UAP's technique will help identify if the issue lies with the equipment or the individual's method.
Choice C rationale:
Demonstrating how to use the equipment might be helpful if the UAP is incorrectly using the thermometer. However, observing the UAP's technique first will help the PN identify if there is a need for retraining or recalibration.
Choice D rationale:
Showing the UAP how to chart temperatures is not the first priority when inconsistent readings are noted. Ensuring the accuracy of temperature measurements is essential for proper patient care and assessment.
Correct Answer is D
Explanation
This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.
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