A nurse is caring for a client in the medical-surgical unit.

Exhibits

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.

Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:

Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.

While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.

Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.

Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.

A. Placing a pillow under the client's knees would not specifically address preventing a compromise in placental blood flow.
B. Reverse Trendelenburg involves tilting the bed so that the head is elevated and the feet are lower. While this position may help with respiratory difficulties (by allowing the diaphragm to expand), it does not address the concern of aortocaval compression, which is critical during pregnancy.
C. The lithotomy position is used for vaginal deliveries and involves placing the client's feet in stirrups, which is not appropriate for a cesarean birth.
D. The wedge position helps maintain blood flow to the placenta by relieving aortocaval compression, thereby improving venous return and placental perfusion. This is particularly important in pregnant clients, where the uterus can exert significant pressure on these blood vessels in the supine position.