A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?
Change the client's position every 2 hr.
Place the client's right hand in a supination position.
Maintain NPO status for the client.
Perform range-of-motion exercises to the client's extremities.
The Correct Answer is C
A. Change the client's position every 2 hr: Repositioning helps prevent skin breakdown and promotes circulation, which is important for stroke clients. However, it does not address the most immediate risk associated with right-sided weakness and facial drooping.
B. Place the client's right hand in a supination position: Proper positioning of the affected extremities prevents contractures and maintains joint alignment. While necessary for long-term care, it is not the highest priority in the immediate post-stroke period.
C. Maintain NPO status for the client: Right-sided weakness and facial drooping indicate potential dysphagia, placing the client at high risk for aspiration. Maintaining NPO status until a swallowing assessment is completed is the priority to prevent aspiration pneumonia, which is a life-threatening complication.
D. Perform range-of-motion exercises to the client's extremities: Range-of-motion exercises prevent contractures and maintain mobility. While important, this intervention is secondary to ensuring the client’s airway safety and preventing aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I don't add salt to my food anymore.": Limiting sodium intake is appropriate for clients with chronic kidney disease (CKD) to help manage fluid retention and blood pressure. This statement reflects proper understanding and does not require additional teaching.
B. "I read nutrition labels before I buy something.": Reading nutrition labels helps clients monitor sodium, potassium, phosphorus, and protein intake, which is essential in CKD management. This demonstrates effective self-management and does not require further teaching.
C. "I'm eating larger portions of meat.": Consuming large portions of meat increases protein and phosphorus intake, which can worsen kidney function and complicate CKD management. This statement indicates a misunderstanding of dietary restrictions, and additional teaching is needed about appropriate protein portion sizes.
D. "I've started using olive oil instead of butter.": Replacing butter with olive oil is appropriate, as it provides healthier fats that do not contribute to hyperphosphatemia or cardiovascular risk. This reflects correct dietary adaptation and does not require further teaching.
Correct Answer is ["1"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 50 mcg
Available Concentration: 100 mcg/2 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (50 ÷ 100) × 2
Volume to administer = 0.5 × 2
Volume to administer = 1 mL
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