A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure.
Which of the following interventions should the nurse include in the plan of care?
Provide a tracheostomy tray at the bedside.
Place the client in a supine position.
Place a plastic tongue depressor at the client's bedside.
Insert an IV saline lock.
The Correct Answer is D
The correct answer is choice D: Insert an IV saline lock.
Choice D rationale: Inserting an IV saline lock is an appropriate nursing intervention for a client with a tonic-clonic seizure. This allows for quick access to administer intravenous medications, such as anticonvulsants, in case the client experiences another seizure.
Choice A rationale: Providing a tracheostomy tray at the bedside is not necessary for seizure precautions. While maintaining a patent airway is essential during a seizure, it can typically be managed with proper positioning and suctioning if necessary.
Choice B rationale: Placing the client in a supine position is not recommended for seizure precautions. Instead, the client should be placed in a semi-prone or lateral position to promote drainage of secretions and prevent aspiration.
Choice C rationale: Placing a plastic tongue depressor at the client's bedside is not an appropriate intervention. Attempting to insert an object into the client's mouth during a seizure can cause injury and is not recommended.
In summary, the nurse should include inserting an IV saline lock as part of the plan of care for a client who has experienced a tonic-clonic seizure. This will allow for rapid administration of medications, if necessary, while prioritizing client safety and adhering to seizure precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Correct Answer is A
Explanation
The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.
Choice A rationale:
Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.
Choice B rationale:
While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.
Choice C rationale:
Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.
Choice D rationale:
Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.
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