A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?

An infant who has respiratory syncytial virus

A child who has bacterial meningitis

An infant who has hypertrophic pyloric stenosis

A child who has Kawasaki disease

Answer and Explanation

The Correct Answer is B

A. An infant who has respiratory syncytial virus (RSV) primarily experiences respiratory symptoms such as wheezing, coughing, and difficulty breathing. RSV does not typically cause seizures.
B. A child who has bacterial meningitis is at high risk for seizures due to increased intracranial pressure, cerebral irritation, and inflammation. Seizure precautions, including padded side rails, oxygen, and suction at the bedside, should be initiated.
C. An infant who has hypertrophic pyloric stenosis experiences projectile vomiting and dehydration but is not at risk for seizures.
D. A child who has Kawasaki disease is at risk for coronary artery complications, but seizures are not a common complication of this condition.

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Correct Answer is D

Explanation

A. Use clean technique for invasive procedures is incorrect because clients with neutropenia require sterile technique for invasive procedures to minimize infection risk.
B. Allow healthy children to visit is incorrect because children can be asymptomatic carriers of infections, which can be life-threatening for immunocompromised clients.
C. Make sure the client's room is cleaned every 2 days is incorrect because a neutropenic client’s room should be cleaned daily to reduce exposure to pathogens.
D. Monitor the client's temperature every 4 hr is correct because even a slight fever can indicate infection, which can be life-threatening for a client with neutropenia. Frequent monitoring allows for early detection and intervention.

A. Forward a completed incident report to the risk manager within 24 hr. B. Notify the facility's pharmacist within 1 hr of the incident. C. Call the nurse who made the error to discuss the medication error. D. Place an incident report in the client's medical record.

Correct Answer is A

Explanation

A. The nurse should complete an incident report and forward it to the risk manager within 24 hours as part of the facility’s protocol for reporting medication errors. This helps track errors, improve safety measures, and prevent future occurrences.
B. While a pharmacist may need to be involved in evaluating the error, there is no requirement to notify them within a specific timeframe. The priority is proper reporting and client monitoring.
C. Calling the nurse who made the error is not an appropriate action. Incident reports focus on improving systems rather than blaming individuals.
D. An incident report is not part of the medical record. It is an internal document used for quality improvement and risk management.

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A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing to administer medication to a client and discovers that a nurse on the previous shift gave the client an incorrect dose of the medication. Which of the following actions should the nurse take?

Correct Answer is A

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