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 urinary catheter.

Apply soft restraints.

Insert a nasogastric tube.

Answer and Explanation

The Correct Answer is A

- Seizure precautions are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness. Seizure precautions include providing a safe environment, monitoring the client's vital signs and neurological status, administering anticonvulsant medications, and documenting the onset, duration, and characteristics of any seizure activity.

- One of the potential complications of a seizure is aspiration, which is the inhalation of foreign material into the lungs, such as saliva, vomit, or food. Aspiration can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiration, the practical nurse (PN) should ensure the ready availability of equipment to perform suctioning of the trachea, which is the tube that connects the mouth and nose to the lungs. Suctioning of the trachea involves inserting a catheter through the nose or mouth into the trachea and applying negative pressure to remove any secretions or debris from the airway.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because inserting a urinary catheter is not related to seizure precautions or aspiration prevention.
Option C is incorrect because applying soft restraints may not be necessary or appropriate for a client who requires seizure precautions, as they may interfere with the natural movements of the seizure or cause injury to the client.
Option D is incorrect because inserting a nasogastric tube is not related to seizure precautions or aspiration prevention.
Suctioning Types

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Correct Answer is C

Explanation

A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.

B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.

C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.

D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.

A. Hold hands folded below the waist after donning sterile gloves. B. Pick up and pour solutions with the palm of the hand covering bottle labels. C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. D. Maintain sterile objects within the line of vision.

Correct Answer is D

Explanation

A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.

B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.

C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.

D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.

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

Nursing Test Bank

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