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 []

Explanation

Rationale:

A: Obtain the latex free cart is incorrect. There is no evidence that the client has a latex allergy or that latex exposure triggered the malignant hyperthermia reaction.

B: Paralytic ileus is incorrect. Paralytic ileus is not the primary condition that the client is experiencing, but a possible secondary complication of malignant hyperthermia.

C: Nausea and vomiting is incorrect. Nausea and vomiting are common postoperative symptoms that may or may not be related to malignant hyperthermia.

D:Malignant hyperthermia (MH) itself does not inherently include hypercapnia as a defining characteristic. However, during an episode of malignant hyperthermia, metabolic acidosis can occur due to the increased production of lactic acid and carbon dioxide as byproducts of the hypermetabolic state. This acidosis can potentially lead to respiratory compensation mechanisms, such as increased respiratory rate and depth, to attempt to eliminate excess carbon dioxide from the body. In some cases, if the compensatory respiratory efforts are insufficient to adequately remove carbon dioxide, hypercapnia can develop as a secondary complication of malignant hyperthermia.

E: nasogastric (NG) tube is incorrect. An NG tube may be indicated for paralytic ileus or bowel obstruction, but not for malignant hyperthermia.

- F: Malignant hyperthermia is correct. The client's vital signs indicate a possible malignant hypertermia reaction, which is a rare but life-threatening complication of general anesthesia that causes a rapid rise in body temperature, muscle rigidity, tachycardia, tachypnea, and hypoxia.

- G: Administer ondansetron is incorrect. Ondansetron is an antiemetic medication that can help with nausea and vomiting, but it does not address the underlying cause of malignant hyperthermia.

- H: Administer dantrolene is correct. Dantrolene is the antidote for malignant hyperthermia and should be given as soon as possible to stop the metabolic crisis and lower the body temperature.

- I: Latex allergy is incorrect. Latex allergy is a hypersensitivity reaction to latex products that can cause urticaria, angioedema, bronchospasm, or anaphylaxis. There is no evidence that the client has a latex allergy or that latex exposure triggered the malignant hyperthermia reaction.

- J: Urticaria is incorrect. Urticaria is a skin rash that can be caused by allergic reactions, infections, or other factors. There is no evidence that the client has urticaria or that it is related to malignant hyperthermia.

- K: Muscle rigidity is correct. Muscle rigidity is one of the signs of malignant hyperthermia and should be monitored closely by the nurse.

- L: Bowel sounds is correct. Bowel sounds should be assessed regularly by the nurse to detect any signs of paralytic ileus, which is a potential complication of malignant hyperthermia that causes intestinal obstruction and abdominal distension.

A. Catheterize the client for residual urine volume B. Measure the next voiding, then palpate the client's bladder C. Evaluate for normal involution, then massage the fundus D. Obtain a specimen for urine culture and sensitivity

Correct Answer is B

Explanation

Urinary output is an important indicator of ﬂuid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess ﬂuid that was retained during pregnancy and the diuretic eﬀect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.

Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.

Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

Correct Answer is B

Explanation

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