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
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Related Questions
Correct Answer is A
Explanation
A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.
B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.
C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.
D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.
Correct Answer is C
Explanation
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
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