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 D
Explanation
A. While seeking help for transportation may be prudent, this statement does not specifically indicate understanding of the risks associated with arrhythmogenic cardiomyopathy.
B. Frequent hiccups are not a typical concern associated with this condition and do not relate to the risk of sudden cardiac death.
C. Constipation is not directly linked to arrhythmogenic cardiomyopathy or its risks.
D. Avoiding competitive recreational sports is critical as it minimizes the risk of arrhythmias and potential sudden cardiac death, indicating a good understanding of the condition’s risks.
Correct Answer is A
Explanation
A. Providing a consistent daily routine helps reduce confusion and anxiety in clients with dementia, aiding in their orientation and functioning.
B. Allowing the client to choose activities can lead to frustration or confusion if they are unable to remember options or make decisions, thus requiring structure.
C. Using an overhead loudspeaker may confuse the client and is not effective for communication; it is often better to provide information in person.
D. Posting a written schedule can be helpful but should be combined with a consistent routine for optimal understanding and orientation. Providing a structured environment is crucial for clients with dementia.