The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining accurate records of intake and output

Maintaining a patent airway

Inserting a nasogastric (NG) tube as prescribed

Providing appropriate pain control

Answer and Explanation

The Correct Answer is B

A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.

B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.

C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.

D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.

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Correct Answer is A

Explanation

A. Agranulocytosis: Carbamazepine carries a boxed warning for serious hematologic effects, including agranulocytosis and aplastic anemia. Agranulocytosis is a significant drop in white blood cell count, leading to a high risk of infection.

B. Birth defects: While carbamazepine is associated with birth defects when taken during pregnancy, the boxed warning specifically highlights the risk of severe blood disorders like agranulocytosis.

C. Skin rash: Carbamazepine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, but the boxed warning focuses more on the hematologic risks.

D. Liver damage: Although carbamazepine can cause liver damage, this is not the primary focus of the boxed warning, which emphasizes hematologic effects.

A. Risk for aspiration B. Risk for falls C. Risk for impaired skin integrity D. Decreased intracranial adaptive capacity

Correct Answer is A

Explanation

A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.

B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.

C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.

D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.

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The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Carbamazepine has a boxed warning for which adverse effect?

Correct Answer is A

Explanation

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Correct Answer is A

Explanation

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