A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?

Pad the upper two side rails of the client's bed.

Maintain peripheral IV access.

Teach assistive personnel how to apply restraints.

Keep a padded tongue blade at the client's bedside.

Answer and Explanation

The Correct Answer is A

A)   Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B)   Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C)   Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D)   Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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Correct Answer is A

Explanation

A. A palpable thrill over the graft site indicates adequate blood flow through the graft.

B. The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C. Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D. A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.

A. Skin turgor B. Urine ketones C. Blood pH greater than expected reference range D. Blood glucose greater than expected reference range E. Creatinine greater than expected reference range

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}

Explanation

A) Slight tenting of the skin indicates dehydration, which is consistent with both DKA and HHS.
B) The presence of ketones in the urine is a hallmark of DKA, as it indicates the body is using fat for energy due to a lack of insulin.
C) A pH of 7.30 is lower than the normal range, suggesting acidosis, which is characteristic of DKA.
D) A blood glucose level of 468 mg/dL is significantly higher than the normal range, which is a common finding in both DKA and HHS.
E) An elevated creatinine level indicates kidney dysfunction, which can be a result of dehydration seen in both DKA and HHS.

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}

Explanation

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?