247SimpleTests
NCLEX · General

A nurse is caring for a client on seizure precautions. Which intervention is appropriate?

Correct answer

Pad the side rails, keep the bed in low position, have suction and oxygen available, and during a seizure protect the head and turn the client to the side — do not restrain or put anything in the mouth

  1. A Restrain the client during a seizure
  2. B Pad the side rails, keep the bed in low position, have suction and oxygen available, and during a seizure protect the head and turn the client to the side — do not restrain or put anything in the mouth
  3. C Insert a tongue blade during a seizure
  4. D Hold the client down firmly

Why this is the answer

SEIZURE PRECAUTIONS and care: PREPARE the environment — pad side rails, keep the bed in LOW position, have SUCTION and OXYGEN available, remove hazards. DURING a seizure: PROTECT the client (cushion/protect the head, turn the client to the SIDE to maintain the airway and prevent aspiration, loosen tight clothing, clear the area, time the seizure, stay with the client). NCLEX safe care/safety. DO NOT: restrain the client (can cause injury), put ANYTHING in the mouth (no tongue blade — risk of injury/airway obstruction; the old myth of swallowing the tongue is false), or hold the client down. AFTER: assess, allow rest (postictal), document. Knowing correct seizure precautions and care (protect, side-lying, never restrain or put objects in the mouth) is a heavily tested NCLEX safety concept.
Source: NCLEX Safe Care — Seizure Precautions

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