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The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?

A.

Provide frequent mouth care.

B.

Maintain the client in a semi-Fowler's position.

C.

Ensure oral suction is available.

D.

Keep the room at a comfortable temperature.

Answer and Explanation

The Correct Answer is C

A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.  

 

B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.  

 

C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.  

 

D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.


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Explanation

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C. While sitting up after meals can aid digestion, it is not a primary dietary instruction for managing diverticulosis.

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Correct Answer is B

Explanation

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