A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Placing the client in the midline position is very key to help prevent muscle imbalance and formation of contractures.

Seizure prophylaxis is important only of the patient had post stroke seizures. However, it is not routinely recommended

Elevated the head prevents the client from aspirating which may lead to choking and aspiration pneumonia.

Encouraging the client to cough- is important in the chronic post stroke phase to prevent respiratory infections due to accumulation of mucus plugs

Oxygen supplementation is not routinely recommended unless the oxygen saturation is recorded to be below 90%