Question

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

a. Place a padded tongue blade at the client's bedside.
b. Keep the side rails lowered on the client's bed.
c. Maintain the client's bed at hip level and above.
d. Ensure the client has a patent IV.

Answer 1

For a patient at risk for seizures, the best practice is to ensure a patent IV for rapid medication administration, elevate and pad side rails for protection, and keep the bed at the lowest level to mitigate fall risk.

Step-by-step explanation:

The question refers to the precautions that a nurse should take when caring for a client at risk for seizures in an acute care facility. In this scenario, the correct action would be to ensure the client has a patent IV. This is critical as it allows for immediate administration of medications should a seizure occur. Additionally, it's important to maintain the side rails at an elevated position and pad them if possible to protect the patient from injury, and keep the bed at the lowest level to reduce the risk of injury from falls. Although once recommended, placing a padded tongue blade at the bedside is no longer considered a safe practice and could cause harm. Low side rails can present a danger of falls and are thus not recommended.