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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip flexion contractures, which can occur after an above-the-knee amputation².
a. Elevating the foot of the bed is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
b. Encouraging sitting up as much as possible is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
c. Elevating the stump on a pillow is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
Correct Answer is B
Explanation
If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.
a. Suggesting that the client use a blunt object such as a comb to relieve the itch is not recommended as it can cause further irritation or damage to the skin.
c. Telling the client to apply lotion to the irritated skin is not recommended as it can cause further irritation or damage to the skin and may also damage the cast.
d. Bivalving the cast is not necessary for skin irritation around the upper edge of the cast. Bivalving involves cutting the cast in half to relieve pressure and is typically only done in cases of severe swelling or compartment syndrome.
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