A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Perform passive range of motion on each extremity.

Record the client's intake and output.

Suction saliva from the client's mouth.

Monitor the client's electrolyte levels.

Answer and Explanation

The Correct Answer is C

The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.

Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.

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Correct Answer is B

Explanation

The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood ﬂow to the area as the body tries to fight oﬀ the infection.

Uneven cast drying, pressure from the cast, and poor circulation are not complications that would cause a warm area on the cast. Uneven cast drying could cause discomfort but would not result in warmth. Pressure from the cast could cause skin breakdown but would not result in warmth. Poor circulation could cause coolness or pallor but would not result in warmth.

A. Apply heat to the area of swelling for the first 48 hr. B. Repeatedly ask the client questions to check for orientation. C. Do not let the client engage in strenuous activities for 1 week. D. Encourage the client to sleep for the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.

Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inﬂammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.

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A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

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