A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Keep the lights on when the client is sleeping.

Restrain the client as soon as seizure activity begins.

Have a padded tongue depressor available at the bedside.

Keep the client's bed in the lowest position.

Answer and Explanation

The Correct Answer is D

A. Keeping the lights on when the client is sleeping is not a standard intervention for seizure precautions. In fact, it's generally recommended to create a quiet and low-stimulus environment for clients with seizure disorders.

B. Restraining the client as soon as seizure activity begins is not recommended. Restraints can lead to injuries and complications during a seizure. It is essential to allow the client to move and prevent injury by removing harmful objects from the vicinity.

C. Having a padded tongue depressor available at the bedside is not a standard intervention for seizure precautions. In the event of a seizure, the priority is to keep the client safe, protect their head, and ensure a clear airway. Placing objects in the mouth is not recommended and can lead to injury.

D. Keeping the client's bed in the lowest position is a safety measure to prevent injuries during a seizure. It reduces the risk of falling from a significant height in case of a seizure episode.

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Correct Answer is C

Explanation

A. Assist a client to eat who has difficulty seeing the foods on the tray.

Assisting a client with eating is a routine task that an AP can perform, especially when the client has difficulty with vision.

B. Provide postmortem care for a client who has died.

Postmortem care involves preparing the body of a deceased client. While it requires sensitivity, it is a task that can be appropriately delegated to assistive personnel.

C. Observe a confused surgical client who has multiple tubes.

Observing a confused client with multiple tubes requires a level of assessment and decision-making that goes beyond the scope of practice for an assistive personnel (AP). This task involves monitoring the client's condition, recognizing changes, and responding appropriately, which should be performed by a licensed nurse.

D. Deliver a client's urine specimen to the laboratory.

Transporting a urine specimen to the laboratory is a task that an assistive personnel can perform, as it does not involve interpretation or assessment of the specimen.

A. Interpreting a client's vital signs B. Providing postmortem care on a client who has died C. Performing a central line dressing change for a client D. Educating a client on the use of a blood glucose monitor

Correct Answer is B

Explanation

A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.

C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.

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A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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