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 B

Explanation

A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.

B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.

C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.

D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.

A. Hematologic spread B. Lymphatic circulation C. Invasion D. Angiogenesis

Correct Answer is A

Explanation

A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.

B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.

C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.

D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.

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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

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Correct Answer is B

Explanation

A client's most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

Correct Answer is A

Explanation

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