In providing care to a client immediately following a tonic-clonic seizure, which activity is best for the practical nurse (PN) to assign to the unlicensed assistive personnel (UAP) working with the PN?
Perform neurologic checks.
Perform oral suctioning.
Place client in a recovery lateral position.
Report the seizure to healthcare provider.
The Correct Answer is C
A. Perform neurologic checks: Neurologic assessments require clinical judgment and interpretation of findings, which are responsibilities of licensed nursing personnel. The UAP cannot independently perform these assessments.
B. Perform oral suctioning: Suctioning is a skilled, potentially invasive procedure requiring assessment of airway patency and client response. It must be performed by licensed staff, not delegated to the UAP.
C. Place client in a recovery lateral position: Positioning the client on their side after a seizure is a safe, non-invasive intervention that helps maintain airway patency and prevent aspiration. This task can be appropriately delegated to the UAP under the PN’s supervision.
D. Report the seizure to healthcare provider: Communication with the provider involves clinical judgment and interpretation of the event. The PN is responsible for reporting detailed clinical information and cannot delegate this task to the UAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rifampin 600 mg PO daily: Rifampin is a standard antitubercular medication known for causing orange discoloration of body fluids and potential hepatotoxicity, but it is not associated with ototoxicity.
B. Gentamicin 160 mg IM daily: Gentamicin is an aminoglycoside antibiotic with a well-documented risk of ototoxicity and nephrotoxicity. The client’s report of tinnitus suggests early ototoxic damage, making it essential for the PN to report this finding immediately to prevent irreversible hearing loss.
C. Pyridoxine with a B complex multivitamin: Pyridoxine (vitamin B6) is commonly prescribed with isoniazid to prevent peripheral neuropathy caused by interference with vitamin metabolism. It does not contribute to tinnitus.
D. Isoniazid 300 mg PO daily: Isoniazid can cause peripheral neuropathy and hepatotoxicity but is not linked to ototoxic effects. The client’s auditory symptoms are unrelated to isoniazid therapy, making gentamicin the priority medication to report.
Correct Answer is D
Explanation
A. Hyperactive bowel sounds on assessment: Increased bowel sounds may be expected postoperatively and with NG suctioning, but they are not immediately life-threatening and do not require urgent reporting.
B. Regular heart rate of 100 beats per minute on telemetry: A heart rate of 100 bpm is at the upper limit of normal for adults and, in the absence of other symptoms, is not an urgent concern.
C. Hypoactive bowel sounds on assessment: Reduced bowel sounds are common after abdominal surgery and with NPO status, but they are not immediately critical unless associated with other signs of obstruction or deterioration.
D. Heart rate of 90 beats per minute with PVCs noted on telemetry: Premature ventricular contractions (PVCs) in the context of dizziness, tingling, and NG suctioning may indicate electrolyte imbalances, such as hypokalemia or hypomagnesemia. This finding should be reported promptly for further evaluation and intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.