A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

Apply restraints if the client is agitated.

Ambulate the client.

Position the client on their side.

Raise all of the side rails on the client's bed.

Answer and Explanation

The Correct Answer is C

A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.

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Correct Answer is C

Explanation

A. Asking "Why do you think that alternative therapies are a better choice?" may come across as judgmental or challenging the client’s decision rather than supporting it. This is not therapeutic.
B. "You should consult with your family before seeking other treatments." assumes that the client’s decision depends on their family, which disregards autonomy.
C. "What has your doctor told you about your treatment options?" is an open-ended question that allows the client to express concerns while ensuring they have the necessary information to make an informed decision. This is the best response.
D. "I will come back to talk to you about your decision when you feel better." invalidates the client’s feelings and delays an important discussion.

A. Choose the client's dominant arm for IV access whenever possible. B. Select a site proximal to previous venipuncture sites. C. Initiate IV access on the palmar side of the client's wrist. D. Insert a larger gauge IV catheter to prevent phlebitis.

Correct Answer is B

Explanation

A. Choose the client's dominant arm for IV access whenever possible. The nondominant arm is preferred to minimize interference with daily activities.
B. Select a site proximal to previous venipuncture sites. This is the appropriate action because using a site above a previous one ensures better vein integrity and reduces complications.
C. Initiate IV access on the palmar side of the client's wrist. This site should be avoided as it is more painful and increases the risk of nerve damage.
D. Insert a larger gauge IV catheter to prevent phlebitis. A smaller gauge catheter is preferred when possible, as larger catheters can increase the risk of vein irritation and phlebitis.

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