The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

Have the client use the call light if they need to get up

Pad the side rails of the client’s bed

Ensure the lights in the room are as bright as possible at all times

Avoid over stimulation and excessive activity in the client’s room

Answer and Explanation

The Correct Answer is C

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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Correct Answer is A

Explanation

A) Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain:
The patient’s refusal to perform these respiratory exercises could lead to serious complications such as atelectasis, pneumonia, and other respiratory issues. Coughing, deep breathing, and using the incentive spirometer are essential to prevent postoperative respiratory complications, especially if the patient is at higher risk for lung issues due to immobility or anesthesia. This needs immediate intervention to ensure the patient understands the importance of these activities and to address the pain issue, potentially with additional pain management or support.

B) Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed:
A urine output of 40 mL/hr is within normal limits for a post-operative patient, and the clear yellow color indicates that the urine is not concentrated or indicative of infection. While monitoring urine output is important postoperatively, this finding suggests adequate renal function and does not indicate an immediate risk for long-term complications.

C) Patient ambulating short distances and performing range of motion exercises after pain is controlled:
Early ambulation and range of motion exercises are encouraged after surgery to promote circulation, prevent blood clots, and support overall recovery. It indicates that the patient is progressing in their recovery and actively participating in post-operative rehabilitation, which is a positive sign and does not need urgent intervention.

D) Hypoactive bowel sounds 2 hours post-operatively:
This is expected immediately after surgery, especially if the patient underwent abdominal surgery or received general anesthesia, which can temporarily reduce bowel motility. Hypoactive bowel sounds within the first few hours post-surgery are a normal response to anesthesia and do not require urgent intervention. The nurse should continue to monitor the patient’s bowel function, but this finding is not a priority in the immediate postoperative period.

A. 15-30g oral carbohydrates. B. 10% dextrose continuous IV infusion C. Glucagon PO, D. 50% dextrose in water (050W) IV push

Correct Answer is D

Explanation

A. 15-30g oral carbohydrates:
Oral carbohydrates are a first-line treatment for hypoglycemia in a conscious, alert patient who can safely swallow. However, since the patient is unresponsive, administering oral carbohydrates is not an appropriate option. The patient’s inability to swallow safely increases the risk of aspiration, making IV treatment the priority in this case.

B. 10% dextrose continuous IV infusion:
A 10% dextrose IV infusion can be used in the management of hypoglycemia, but in an acute, emergency setting where the patient is unresponsive and their blood glucose is critically low (30 mg/dL), a rapid-acting intervention is needed. A bolus dose of a concentrated solution, such as 50% dextrose, is more appropriate for quickly raising the blood glucose level in this situation, rather than a continuous infusion, which takes longer to achieve an effective increase in glucose.

C. Glucagon PO:
Glucagon is typically used for hypoglycemia in patients who are unconscious or unable to take oral glucose. However, glucagon is typically administered intramuscularly (IM) or subcutaneously (SQ), not orally (PO). Administering glucagon orally is ineffective, as it would not be absorbed by the body in the necessary manner to correct hypoglycemia. Therefore, this option is inappropriate.

D. 50% dextrose in water (50% DW) IV push:
When a patient is unresponsive and their blood glucose level is critically low (30 mg/dL), the priority treatment is an immediate, concentrated source of glucose. Administering 50% dextrose IV push is the most appropriate intervention in this scenario. It provides a rapid and effective increase in blood glucose levels, which is critical for reversing hypoglycemia in an emergency situation. This is the fastest and most direct approach to treating severe hypoglycemia in an unresponsive patient.

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The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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