A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?
Oral suction equipment
Tongue depressor
Tracheostomy tray
Wrist restraints
The Correct Answer is A
A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Sit back down for a few minutes when this occurs.": This is correct. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effect. The client should be advised to sit down to prevent falls and allow the body to adjust.
B. "Take a daily potassium supplement.": This is incorrect. ACE inhibitors can increase potassium levels, and taking a potassium supplement without a healthcare provider’s recommendation may lead to hyperkalemia, a dangerous condition.
C. "Restrict your daily fluid intake.": This is incorrect. Dehydration can exacerbate hypotension, so it is not recommended to restrict fluid intake without further instructions from the provider.
D. "Discontinue this medication if this occurs again.": This is incorrect. The client should not discontinue medication without first consulting their healthcare provider. The healthcare provider may adjust the dosage or provide alternative recommendations to manage the side effects.
Correct Answer is B
Explanation
A. Removing personal protective equipment (PPE. after leaving the room is incorrect because it should always be done before leaving the client's room to ensure the nurse does not accidentally spread the infection. Proper removal of PPE is crucial to preventing transmission.
B. Wearing a gown when assisting the client with personal hygiene is correct. MRSA is typically spread through direct contact, so wearing a gown when providing personal care (e.g., assisting with hygiene. helps prevent the spread of MRSA. Additionally, gloves and other PPE should also be worn.
C. Negative air pressure is typically required for airborne precautions, such as for clients with tuberculosis, but not for MRSA, which is transmitted via contact. Therefore, this is not necessary for MRSA care.
D. Restricting the client's visitors is not necessary unless the client has an infection that requires isolation precautions beyond what is standard for MRSA. MRSA can be controlled with contact precautions, and visitor restrictions are generally not part of standard MRSA isolation.
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