A 67-year-old client suffered a cerebral vascular accident (CVA) three days ago and is to receive his morning medication. Upon talking with the client, the nurse notices that his speech is more slurred than yesterday. What action should the nurse take first?
a. Obtain vital signs of the client, wait on administering the medication, and call the physician.
b. Give the morning medication, and observe the client.
c. Give the medication, and see if the client can swallow.
d. Ask the client if he can swallow.
a. Obtain vital signs of the client, wait on administering the medication, and call the physician.
FEEDBACK:
a. Obtain vital signs (temperature, pulse, blood pressure, and respiratory rate) of the client, wait on administering the medication, and call the physician. It is the responsibility of the nurse to look out for the well-being of this client and the potential for aspiration.
b. Giving the morning medication and observing the client is insufficient because the client's situation has changed. Try again.
c. Giving the morning medication and determining if the client can swallow could be problematic if the client aspirates while trying to swallow. Try again.
d. Asking the client if he can swallow can be helpful, but this is not the best action. Try again.
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