Examkin

Question

Difficulty: MediumAccident, Error, and Injury Prevention

During interdisciplinary rounds, the healthcare team discusses safety interventions for a client with a history of prolonged generalized tonic-clonic seizures. Which action demonstrates adherence to proper injury prevention protocols?

  1. Maintain functioning suction apparatus and a supplemental oxygen delivery system at the bedside.Answer
  2. B
    Secure all four bed side rails in the upright position whenever the client is left unattended.
  3. C
    Assign the unlicensed assistive personnel to perform continuous neurological monitoring during the postictal phase.
  4. D
    Administer intravenous phenytoin piggybacked into a continuous infusion of dextrose 5% in water.

Answer

The correct action is to ensure that functioning suction equipment and supplemental oxygen are readily available at the client's bedside.
During a generalized tonic-clonic seizure, the client is at high risk for hypoxia, excessive salivation, and aspiration. Having functioning suction apparatus and oxygen immediately available at the bedside ensures the nurse can rapidly clear and support the airway once the active seizure concludes, thereby preventing severe respiratory complications and maintaining the care environment's safety.

Step-by-Step Solution

1
Identify the primary physiological risks associated with generalized tonic-clonic seizures.
The main risks during and immediately after a seizure include airway compromise, aspiration of secretions, and physical trauma.
Understanding the pathophysiology of the condition dictates the necessary preventative safety measures.
2
Evaluate each proposed intervention against standard safety and error-prevention guidelines.
Only preparing airway management tools aligns with safety standards. Raising four side rails acts as a hazardous restraint, unlicensed assistive personnel cannot perform clinical assessments, and phenytoin precipitates in dextrose.
Evidence-based practice requires implementing proactive measures that minimize iatrogenic harm and promote respiratory safety.

Key Concept

Seizure precautions prioritize airway management and the avoidance of restrictive or physiologically harmful interventions.
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic