The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)
Ensure oral suction is available.
Provide frequent mouth care.
Keep the room at a comfortable temperature.
Maintain the client in a semi-Fowler's position.
The Correct Answer is A
A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.
C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.
D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.
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Related Questions
Correct Answer is D
Explanation
A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.
B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.
C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.
D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.
Correct Answer is D
Explanation
A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.
B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.
C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.
D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.
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