A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.

A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.

D. After treatment for primary syphilis, it is essential for the client to have follow-up blood tests to monitor their response to treatment and ensure that the infection has been adequately treated. The follow-up blood tests are typically performed at 3, 6, and 12 months after treatment to check for resolution of the infection.
A. Syphilis is caused by a bacterial infection, not a virus. Therefore, antiviral medications are not effective for treating syphilis.
B. Cryotherapy, which involves freezing off warts or abnormal tissue, is not a treatment for syphilis.
C. Monitoring for 15 minutes after receiving each medication dose is a standard precaution for certain medications, such as vaccines or allergy injections, to monitor for any immediate adverse reactions. However, it is not necessary for syphilis.