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 B
Explanation
Digoxin is a medication used to treat various heart conditions, such as abnormal heart rhythms and heart failure.It works by improving the strength and efficiency of the heart, or by controlling the rate and rhythm of the heartbeat.
One of the important things to monitor when giving digoxin to an infant is the pulse rate. Digoxin can lower the heart rate, which can be dangerous if it becomes too slow.Therefore, the pulse rate should be checked for one full minute before administering digoxin, and the medication should be held if the pulse rate is below 90 beats per minute (bpm) for an infant.
In this case, the infant’s heart rate is 120 bpm, which is within the normal range for a 2-month-old. Therefore, the correct action for the PN to take is to administer the medication and document the heart rate. This is optionbin the list of choices. Optionais incorrect because there is no need to hold the medication or recheck the heart rate in one hour. Optioncis incorrect because there is no need to alert the charge nurse unless there is a problem with the infant’s condition or the medication. Optiondis incorrect because holding the medication and documenting cardiac assessment is not appropriate for a normal heart rate.
Correct Answer is D
Explanation
The correct answer is choice D. Apply a pain scale to describe intensity.
Choice A rationale:
Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.
Choice B rationale:
Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.
Choice C rationale:
Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.
Choice D rationale:
Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.
By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.
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