A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. A respiratory therapist focuses on breathing and airway management, which is not the primary concern for a client needing strengthening after a stroke.
B. An occupational therapist helps clients with daily living activities and fine motor skills, but the focus on strengthening the affected side is more specific to physical therapy.
C. A physical therapist specializes in developing and implementing exercise programs to strengthen muscles and improve mobility, making this the most appropriate referral for the client's needs.
D. A social worker assists with emotional and social needs but would not focus on physical rehabilitation after a stroke.
Correct Answer is A
Explanation
A. Dyspnea can indicate heart failure or embolic events resulting from infective endocarditis, making it a serious complication that warrants attention.
B. Fever is a common symptom of infective endocarditis due to the infection but is not a complication; rather, it is part of the disease process.
C. Petechiae are small red or purple spots that can occur with infective endocarditis but are also not considered a complication, rather a manifestation of the condition.
D. A heart murmur may be present due to valvular damage but is not classified as a complication; it is a common finding in infective endocarditis.