Which client statements require follow-up teaching by the nurse? Select all that apply.

Choice A rationale

Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.

Choice B rationale

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.

Choice C rationale

Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.

Choice D rationale

Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.

Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:

• C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
• D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.