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.
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Related Questions
Correct Answer is A
Explanation
The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.
b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.
Correct Answer is D
Explanation
The nurse should reinforce to the client that Buck's traction promotes relief from muscle spasms. Buck's traction is a type of skin traction that is widely used for fractures of the femur and hip². It uses splints, bandages, and adhesive tapes to position a limb near the fracture and then applies pressure using weights and pulleys. One of the goals of Buck's traction is to lessen or eliminate muscular spasms.
a. Reduction of the fracture is not the primary purpose of Buck's traction.
b. Support for moving the extremity is not a primary outcome of Buck's traction.
c. Alignment of the pins is not applicable to Buck's traction as it does not involve inserting pins into the
bone.
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