The nurse plans care for a client with a suspected stroke. What action should the nurse include to support airway protection?

A. Assess for cerumen impaction or foreign bodies in the ear canal is the priority action because conductive hearing loss occurs when sound waves are blocked from reaching the inner ear, often due to cerumen buildup, foreign bodies, or fluid in the middle ear. Identifying and removing these obstructions can restore hearing or significantly improve it. Assessment is the first step before implementing other interventions.

B. Refer the client for cochlear implant evaluation is inappropriate for conductive hearing loss, as cochlear implants are designed for sensorineural hearing loss where the inner ear or auditory nerve is damaged. This intervention does not address the underlying problem in conductive hearing loss.

C. Speak loudly and slowly while facing the client is a helpful communication strategy but is not a treatment or priority action for managing conductive hearing loss. It does not address the underlying cause.

D. Encourage the client to avoid noisy environments may help with hearing clarity, but it is secondary to identifying and treating the cause of the hearing loss. Avoiding noise does not correct the obstruction causing conductive hearing loss.

A. While temperature is an important vital sign, it is not directly related to cardiac rhythm or dysrhythmias. Abnormal temperature may influence heart rate indirectly (e.g., fever causing tachycardia), but it is not the priority assessment for a client with known cardiac dysrhythmias.

B. Pulse oximetry measures oxygen saturation and can indicate hypoxia. Although oxygenation is important, dysrhythmias primarily affect heart rate and rhythm rather than oxygen saturation directly. It is secondary to assessing the pulse in this context.

C. The pulse is the most critical vital sign to assess in a client with a history of cardiac dysrhythmias. Evaluating the rate, rhythm, and quality of the pulse allows the nurse to identify irregularities such as tachycardia, bradycardia, skipped beats, or other arrhythmias. Dysrhythmias can lead to decreased cardiac output, hypotension, syncope, or sudden cardiac events, so prompt identification is essential for timely intervention.

D. Respiratory rate is important for overall assessment, especially if dysrhythmias compromise cardiac output, but it is not the primary indicator of cardiac rhythm issues. It is a secondary assessment compared with the pulse.