In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

C.Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client may experience uncontrolled movements and convulsions. Placing pillows around the bed rails helps prevent injury by providing padding and cushioning.

E.Increase the supplemental oxygen to 10 L/min via nasal cannula: The client's oxygen saturation is dangerously low at 40%. Increasing the supplemental oxygen to 10 L/min via nasal cannula will help improve oxygenation and prevent hypoxia.

F.Manually ventilate the client with a bag-valve-mask: Since the respiratory rate is only 4 breaths/min, the client is not adequately ventilating on their own. Manual ventilation with a bag-valve maskwill provide necessary oxygenation and ventilation support during the seizure.

The other options are not appropriate actions at this time:

• Begin chest compressions: Chest compressions are indicated if the client's heart has stopped or if they are in cardiac arrest. Since the scenario describes a seizure, the client's heart is presumed to be functioning.
• Watch the seizure activity and document the time and client movement: Although documentation is important, during an active seizure, the priority is to ensure the client's safety and provide immediate interventions. Documentation can be done after the seizure has ended.
• Stop the IV fluids: There is no indication to stop the IV fluids based on the given information. IV fluids are generally continued unless there is a specific reason to discontinue them.

Choice A: Document the client's loss of memory in the record.

While it's important to document changes in a patient's condition, this should not be the first action. The confusion might be temporary and due to the new environment. It's crucial to first address the patient's immediate needs.

Choice B: Remind the client what day of the week it is.

This is the best action to take. The patient is likely experiencing "relocation stress syndrome," which can cause confusion and disorientation in a new environment. Reminding her of the day can help reorient her and alleviate her confusion.

Choice C: Encourage the client to rest during the day.

While rest is important, it doesn't directly address the patient's confusion about the day of the week. Furthermore, excessive daytime sleep can disrupt the patient's sleep-wake cycle and potentially exacerbate confusion.

Choice D: Notify the family of the change in the client's condition.

While it's important to keep the family informed, this should not be the first action. The nurse should first address the patient's confusion and monitor her to see if the confusion persists or improves.