The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which of the item(s) need to be placed at the child bedside?

Tracheotomy set

Emergency cart

Padded tongue blade

Suctioning equipment and oxygen

Answer and Explanation

The Correct Answer is D

D. Suctioning equipment and oxygen are essential items to have at the bedside for seizure precautions. Seizures can sometimes be associated with airway compromise, excessive secretions, or respiratory distress. Having suctioning equipment readily available allows for prompt removal of oral or airway secretions if necessary. Oxygen may be needed to support oxygenation during or after a seizure, especially if there are concerns about respiratory depression or hypoxemia.

A. A tracheotomy set is not typically needed at the bedside for seizure precautions. Tracheotomy sets are used in emergency situations to establish a surgical airway if there is a severe airway obstruction or respiratory distress.

B. An emergency cart contains essential supplies and medications needed for emergency situations, including resuscitation equipment, medications, and supplies for managing various medical emergencies. However, the cart is not placed bedside.

C. A padded tongue blade is not typically needed at the bedside for seizure precautions. Tongue blades are sometimes used during airway management to help visualize and manipulate the tongue, but padded tongue blades are not routinely included in seizure precautions.

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Correct Answer is D

Explanation

D. An oxygen saturation level of 85% is significantly below the normal range and indicates hypoxemia (low blood oxygen levels). This finding is concerning, especially in a child with cystic fibrosis, which can lead to respiratory complications such as airway obstruction, infection, or mucus plugging.

A. A blood glucose level of 140 mg/dL is within the normal range for children, so this finding would not typically require immediate reporting to the provider.

B. A serum sodium level of 156 mEq/L is significantly elevated and above the normal range. However, hypoxia is the priority.

C. A red blood cell (RBC) count of 3.2 million/µL falls within the normal range for children, so this finding would not typically require immediate reporting to the provider.

A. Use a hair dryer on a hot setting to dry the cast. B. Discourage the client from ambulating. C. Keep the client's leg in a dependent position. D. Perform a neurovascular check of the lower extremities.

Correct Answer is D

Explanation

D. This is the correct action to take. A neurovascular check involves assessing the circulation, sensation, and movement in the affected limb. This check helps monitor for complications such as impaired circulation, nerve damage, or compartment syndrome, which can occur after the application of a plaster cast. Regular neurovascular checks are essential for early detection of any issues and appropriate intervention if necessary.

A. Using a hair dryer on a hot setting can cause burns to the skin under the cast. It can also cause the cast material to heat up and potentially cause discomfort or injury to the patient.

B. It's essential to follow the healthcare provider's instructions regarding weight-bearing restrictions, but completely discouraging ambulation can lead to complications such as muscle atrophy, decreased circulation, and increased risk of blood clots.

C. Keeping the client's leg in a dependent position means positioning it lower than the heart. This can increase swelling and exacerbate pain, potentially leading to complications such as compartment syndrome.

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The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which of the item(s) need to be placed at the child bedside?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately?

Correct Answer is D

Explanation

A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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