A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
A.
Perform passive range of motion on each extremity.
B.
Record the client’s intake and output.
C.
Suction saliva from the client’s mouth.
D.
Monitor the client’s electrolyte levels.
The Correct Answer and Explanation is:
The correct answer is:
C. Suction saliva from the client’s mouth.
Explanation:
When caring for an unconscious client, the highest priority is always maintaining a patent airway. This aligns with the ABCs of emergency care: Airway, Breathing, and Circulation. In this case, suctioning saliva from the client’s mouth is critical to prevent aspiration, which could lead to serious complications like pneumonia, or even respiratory failure.
Clients who are unconscious, particularly following a stroke, are at significant risk of losing protective reflexes, such as the gag and cough reflexes. Without these reflexes, the client is unable to clear their airway effectively, making them highly susceptible to aspiration of saliva, mucus, or even gastric contents. This can lead to aspiration pneumonia, a potentially life-threatening condition that requires immediate attention. By suctioning the saliva from the client’s mouth, the nurse ensures the airway is clear, reduces the risk of aspiration, and helps prevent respiratory complications.
While the other interventions in the options are important for overall client care, they are not as immediately critical as maintaining the airway:
- A. Perform passive range of motion on each extremity: This is helpful in preventing contractures and promoting circulation, but it is not the highest priority when airway management is required.
- B. Record the client’s intake and output: Monitoring fluid balance is essential for maintaining overall homeostasis, but it does not take precedence over airway management in an unconscious client.
- D. Monitor the client’s electrolyte levels: While electrolyte imbalances can lead to complications such as cardiac arrhythmias or neurological changes, addressing immediate airway needs is the most urgent concern.
In summary, suctioning the client’s airway is the highest-priority intervention to ensure the client’s safety and prevent respiratory complications, which can be fatal if not addressed immediately.