The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)
Ensure oral suction is available.
Provide frequent mouth care.
Keep the room at a comfortable temperature.
Maintain the client in a semi-Fowler's position.
The Correct Answer is A
A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.
C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.
D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To calculate the infusion rate in mL/hr, you would convert the total volume of lactated Ringer's IV from liters to milliliters (since there are 1,000 milliliters in a liter, 3 liters is equivalent to 3,000 milliliters) and then divide by the total number of hours over which the infusion is to be administered. In this case, 3,000 mL divided by 24 hours results in an infusion rate of 125 mL/hr.
Correct Answer is ["0.4"]
Explanation
To determine the correct dosage, the nurse needs to perform a calculation using the information provided. The prescription is for 200,000 units of penicillin, and the available vial concentration is 500,000 units per mL.
To find out how many mLs to administer, the nurse would divide the prescribed units by the concentration of units per mL. This is calculated as 200,000 units divided by 500,000 units/mL, which equals 0.4 mL.
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