A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?

Rationale:

A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.

B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.

C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.

D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.