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A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

A.

Monitor the client's electrolyte levels.

B.

Perform passive range of motion on each extremity.

C.

Suction saliva from the client's mouth.

D.

Record the client's intake and output.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

A. A sedentary lifestyle is a risk factor for various cardiovascular diseases but is not specifically associated with pericarditis.

B. A recent flu-like illness can increase the risk of viral infections, which are common causes of pericarditis, making it an important risk factor to mention.

C. Thyroid disease can influence cardiovascular health but is not a direct risk factor for developing pericarditis.

D. While a family history may indicate a predisposition to some heart diseases, there is no strong association with pericarditis specifically.

Correct Answer is ["A","B","D"]

Explanation

A. Pain behind the ear is a common early symptom of Bell's palsy due to inflammation of the facial nerve.

B. Muscle distortion occurs as the facial muscles on the affected side weaken or become paralyzed, leading to an asymmetrical appearance.

C. Facial twitching is not a common manifestation of Bell's palsy; rather, it involves muscle paralysis or weakness.

D. Impaired taste, especially in the anterior two-thirds of the tongue, can occur due to facial nerve involvement.

E. Hearing loss is not typically associated with Bell's palsy; it usually affects facial motorfunction, not auditory function.

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