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 B

Explanation

A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.

A. Alert and orientated x4 B. Heart and lung sounds clear C. Client urinating 100 mL/hour D. Client is tolerating soft diet and oral fluids E. Bilateral pedal pulses 2+ F. Temperature 36.8° C (98.2° F) G. Pulse rate 84/min H. Respiratory rate 16/min I. Blood pressure 106/76 mm Hg J. Oxygen saturation 96% on room air

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The

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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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Explanation

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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?