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A 32 weeks patient is admitted to the maternity unit with severe preeclampsia. While her vital signs are being checked by the nurse she goes into convulsion, Which nursing action would be contraindicated in caring for the patient during an episode of convulsive eclampsia?
a. Not leaving the client
b. Keeping air passages clear of secretions
c. Firmly restraining the client to prevent injury
d. Having side rails up and padded
Step by step
Solved in 2 steps
- What are the first action(s) the nurse would do when entering a room with a patient in respiratory distress? (Select all that apply) A. assess breath sounds B.provide incentive spirometer C.Begin CPR D. raise the head of the bed E. Apply oxygenA nurse is caring for a patient who has a nasogastric tube inplace for gastric decompression. Which nursing actions areappropriate when irrigating a nasogastric tube connected tosuction? Select all that apply.a. Draw up 30 mL of saline solution into the syringe.b. Unclamp the suction tubing near the connection site toinstill solution. c. Place the tip of the syringe in the tube to gently insertsaline solution.d. Place syringe in the blue air vent of a Salem sump ordouble-lumen tube.e. After instilling irrigant, hold the end of the NG tube overan irrigation tray.f. Observe for return flow of NG drainage into an availablecontainer.A nurse is caring for a patient who has a nasogastric tube inplace for gastric decompression. Which nursing actions areappropriate when irrigating a nasogastric tube connected tosuction? Select all that apply.a. Draw up 30 mL of saline solution into the syringe.b. Unclamp the suction tubing near the connection site toinstill solution.
- The nurse is administering a medication to a patient via anasogastric tube. Which are accurate guidelines related to thisprocedure? Select all that apply.a. Crush the enteric-coated pill for mixing in a liquid.b. Flush open the tube with 60 mL of very warm water.c. Check for proper placement of the nasogastric tube.d. Give each medication separately and flush with waterbetween each drug.e. Lower the head of the bed to prevent reflux.f. Adjust the amount of water used if patient’s fluid intake isrestricted.The practical nurse (PN) is assigned to care for a client that is unconscious and at risk for aspiration. The PN prepare oral care to the client as seen in the picture. Which action should the PN take next? A Put the foam toothette between the lips. B Position an emesis basin under the chin.C Place the client in a side-lying position.D Insert an oral airway into the oropharynx.A patient who is moved to a hospital bed following throat sur-gery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of thetube, which nursing action would the nurse initiate to ensurecorrect placement of the tube?a. Auscultate the bowel sounds.b. Measure the gastric aspirate pH.c. Measure the amount of residual in the tube.d. Order radiographic examination of the tube.
- A nurse providing care of a patient’s chest drainage systemobserves that the chest tube has become separated from thedrainage device. What would be the first action that shouldbe taken by the nurse in this situation?a. Notify the physician.b. Apply an occlusive dressing on the site.c. Assess the patient for signs of respiratory distress.d. Put on gloves and insert the chest tube in a bottle of sterilesaline.A nurse is reconstituting powdered medication in a vial.Which action is a recommended step in this process? a. The nurse draws up the proper amount of powered medica-tion into the syringe. b. The nurse inserts the needle through the rubber stopper ofthe diluent vial.c. The nurse gently agitates the powdered medication vial tomix the powder and diluent completely.d. The nurse draws up the prescribed amount of medicationwhile holding the syringe horizontally at eye level.
