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.
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Related Questions
Correct Answer is B
Explanation
A. Beneficence: Beneficence refers to the ethical principle of promoting good and acting in the best interest of the client. While this guides nursing actions to provide beneficial care, it does not directly involve respecting a client’s decision to refuse treatment.
B. Autonomy: Autonomy is the ethical principle that recognizes the client’s right to make independent decisions about their own healthcare. Respecting the client’s decision to refuse treatment honors their personal values, beliefs, and right to self-determination, even if the nurse disagrees with the choice.
C. Nonmaleficence: Nonmaleficence involves the obligation to avoid causing harm to the client. While important in all nursing actions, it focuses on preventing harm rather than specifically supporting a client’s right to make healthcare decisions.
D. Justice: Justice refers to fairness in the distribution of healthcare resources and treatment. It ensures equitable care for all clients but is not directly related to respecting an individual client’s choice to accept or refuse treatment.
Correct Answer is C
Explanation
A. The infant is swaddled but there is a blanket and a stuffed toy in the crib. Loose items increase the risk of suffocation and SUID, so this does not demonstrate safe sleep practices.
B. The infant is placed on their back, but there is a blanket and a stuffed toy in the crib. These items pose a suffocation risk and do not follow safe sleep guidelines.
C. The infant is placed on their back in a swaddle with no loose blankets or toys in the crib. This position aligns with American Academy of Pediatrics (AAP) recommendations for safe sleep to reduce the risk of SUID, demonstrating proper understanding of safe sleep practices.
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