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.
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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 C
Explanation
A. The recommended sodium intake for individuals with hypertension is typically less than 2,300 mg per day, so a goal of 3,000 mg is too high.
B. For individuals with hypertension, it is recommended to limit alcohol consumption to 1 drink per day for women and 2 drinks per day for men, so 3 drinks is excessive.
C. Planning to have potassium blood levels checked when taking thiazide diuretics is important because these medications can lead to hypokalemia (low potassium levels), making this the correct response.
D. Setting a goal body weight within 25% of ideal body weight is not a standard recommendation; weight management should focus on achieving a healthy weight, rather than a specific percentage of ideal body weight.