A nurse working on a medical unit is caring for a patient who is placed on seizure precautions. Which of the following interventions should the nurse include in the patient's plan of care?
Keep a padded tongue blade available at the patient's bedside.
Place the patient's bed in the high position.
Keep the lights on when the patient is sleeping.
Obtain IV access.
The Correct Answer is D
A. Incorrect. Never insert anything into a seizing patient's mouth, as it can cause injury.
B. Incorrect. The bed should be in the lowest position to prevent falls.
C. Incorrect. Keeping lights on is unnecessary and can cause sensory overstimulation.
D. Correct. IV access is important in case emergency medications (e.g., lorazepam) are needed during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Give potassium intravenously. – The potassium level is 3.7 (within normal range 3.5–5.0), so potassium is not needed yet.
B. Administer D5 NS with the insulin drip. – Correct Answer. Once glucose drops to ≤200 mg/dL, dextrose is added to prevent hypoglycemia while continuing insulin to correct ketoacidosis.
C. Administer 3% NS at 200 mL/hr. – Hypertonic saline is used for severe hyponatremia, which is not the case here.
D. Expect the insulin drip to be discontinued. – The insulin drip is not discontinued until ketoacidosis has fully resolved (when HCO3 > 18, pH > 7.3, and anion gap normalizes).
Correct Answer is A
Explanation
A. Correct. A platelet count <20,000/μL increases bleeding risk. Checking for occult blood helps detect hidden gastrointestinal bleeding.
B. Incorrect. Hydration is important but does not directly address thrombocytopenia management.
C. Incorrect. While oral hygiene is important, frequent brushing could cause bleeding with low platelets.
D. Incorrect. Monitoring temperature is important for infection risk but does not address bleeding concerns.
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