Question

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply.

1.Padding the side rails of the bed
2.Placing an airway at the bedside
3.Placing the bed in the high position
4.Putting a padded tongue blade at the head of the bed
5.Placing oxygen and suction equipment at the bedside
6.Flushing the intravenous catheter to ensure that the site is patent

Answer 1

For seizure precautions, the nurse should include padding the side rails, having an airway and oxygen plus suction equipment at the bedside, and checking that the intravenous catheter is patent. Bed should not be in a high position and padded tongue blades should not be used.

Step-by-step explanation:

The nurse is instituting seizure precautions for a client being admitted into a healthcare setting, several measures should be included to ensure the client's safety. These include:

1. Padding the side rails of the bed to prevent injury during a seizure.
2. Placing an airway at the bedside to maintain airway patency if respiratory intervention is needed.
3. Placing oxygen and suction equipment at the bedside, readily available for respiratory support or to clear secretions.
4. Ensuring that the intravenous catheter is patent by flushing it, which is crucial for administering medications during or after a seizure.

It is important to note that placing the bed in a high position and putting a padded tongue blade at the head of the bed are not recommended as they could pose additional risks to the patient.

The steps for establishing safety protocols align with practices across various medical procedures, such as the methods outlined by Dr. Pronovost for central line insertion in ICUs, which include checklists to ensure all safety measures are in place. Additionally, nurses play a critical role in confirming these safety measures during team reviews, as part of standard procedural checks before and after medical interventions such as surgeries or in response to patients with special needs like seizure disorders.

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