A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure.
Which of the following interventions should the nurse include in the plan of care?
A.
Provide a tracheostomy tray at the bedside.
B.
Place the client in a supine position.
C.
Place a plastic tongue depressor at the client’s bedside.
D.
Insert an IV saline lock.
The Correct answer and Explanation is:
The correct answer is:
D. Insert an IV saline lock.
Explanation:
When caring for a client who has experienced a tonic-clonic seizure, seizure precautions are essential to ensure safety and prepare for potential emergencies. Among the listed options, inserting an IV saline lock is the most appropriate intervention.
Rationale for Answer D:
- IV Access: Having an IV saline lock readily available is crucial in clients with a history of seizures. This allows quick administration of medications, such as benzodiazepines, which may be necessary to control or stop a seizure if it occurs. Rapid access to the bloodstream is critical in emergencies, and inserting an IV lock beforehand saves valuable time.
- Other Considerations: This intervention is also part of preparing for potential complications, such as status epilepticus, where prolonged seizures could necessitate immediate intravenous treatment. The IV lock provides a ready route for fluids, electrolytes, and other necessary medications.
Rationale Against Other Options:
A. Provide a tracheostomy tray at the bedside:
- This is not typically included in seizure precautions. Tracheostomy trays are used in airway emergencies, but they are not specifically needed for seizure management unless the client has an existing tracheostomy or is at high risk for respiratory obstruction. For most seizure-prone clients, ensuring airway patency through positioning is sufficient.
B. Place the client in a supine position:
- Placing a client in a supine position during or after a seizure is unsafe. A side-lying position is preferred because it helps maintain an open airway and prevents aspiration in case of vomiting. Supine positioning increases the risk of airway obstruction and aspiration.
C. Place a plastic tongue depressor at the client’s bedside:
- Using or placing objects like tongue depressors in a client’s mouth during a seizure is contraindicated. It can cause injury to the client, such as broken teeth or choking. The correct approach is to protect the client from injury by clearing the area of hazards and providing padding.
Conclusion:
Seizure management requires a proactive approach, with the primary goal being the client’s safety. Among the options, inserting an IV saline lock is the most appropriate, as it prepares for any required interventions without causing harm or exposing the client to unnecessary risks.