# A nurse is caring for an unconscious client in the intensive care unit. Which nursing intervention is the highest priority to ensure client safety? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541112 > language: ko > subject: Adult Health ## 문제 A nurse is caring for an unconscious client in the intensive care unit. Which nursing intervention is the highest priority to ensure client safety? ## 보기 1. Perform passive range-of-motion exercises every 2 hours 2. Monitor blood pressure and heart rate every 15 minutes 3. Suction the airway as needed to maintain clear secretions 4. Position the client in side-lying position to prevent aspiration **✔ 정답** **정답: 4** ## 해설 Positioning in side-lying is the highest priority safety intervention to prevent aspiration, a life-threatening risk in unconscious clients. Other measures like ROM exercises and vital sign monitoring are important but do not address immediate airway safety. ## 심화 해설 Understanding the Priority: Airway Management in the Unconscious Client For an unconscious client, the loss of protective airway reflexes, including the gag and cough reflexes, creates an immediate and life-threatening risk. The highest priority is always ensuring a patent airway to prevent airway obstruction and aspiration, which aligns with the "ABC" (Airway, Breathing, Circulation) framework fundamental to nursing care and resuscitation. While all listed interventions are important aspects of care, airway maintenance takes precedence because without a clear airway, all other interventions become futile. Why Positioning is the Highest Priority Positioning an unconscious client in a side-lying position (lateral recumbent or recovery position) is the most critical safety intervention. This position uses gravity to drain secretions, vomitus, or blood from the mouth, preventing them from entering the trachea and lungs. The tongue, which is the most common cause of airway obstruction in an unconscious client due to loss of muscle tone, will also fall to the side of the oropharynx rather than collapsing directly backward to block the airway. This simple maneuver directly addresses the two primary airway threats: mechanical obstruction and aspiration [1]. The foundational importance of this intervention is rooted in the principles of basic airway management (BAM). BAM is described as the cornerstone of pre-hospital and emergency care, representing the essential, non-invasive techniques required to establish and maintain a patent airway [1]. For any healthcare provider, including nurses, the competence to perform these maneuvers is a non-negotiable first step before any advanced intervention. The side-lying position is a quintessential BAM technique that can be performed immediately and without equipment, making it the highest-priority action upon identifying an unconscious client. Analyzing the Other Options - Option 1: Perform passive range-of-motion exercises every 2 hours. This intervention addresses the long-term risk of contractures and muscle atrophy related to immobility. While important for preventing musculoskeletal complications, it does not address an immediate threat to life. The airway, breathing, and circulation must be secured first. - Option 2: Monitor blood pressure and heart rate every 15 minutes. This intervention addresses the "Circulation" component of the ABCs. In an unstable client, frequent vital sign monitoring is crucial. However, in the hierarchy of physiological needs, a compromised airway will lead to fatal hypoxia and cardiac arrest far more rapidly than a hemodynamic change that is being monitored. The airway must be secured before or concurrently with circulatory assessment, but the intervention to secure the airway takes priority over the monitoring of circulation. - Option 3: Suction the airway as needed to maintain clear secretions. Suctioning is a critical intervention for clearing an already compromised airway. However, it is a reactive measure. The side-lying position is a proactive, preventive measure that continuously minimizes the accumulation of secretions and risk of aspiration. Furthermore, effective suctioning requires preparation and equipment, whereas positioning can be done instantly. The principle of BAM emphasizes the least invasive maneuver first; positioning is that first step, with suctioning as a necessary adjunct when secretions are present [1]. The nurse would position the client and then, if gurgling respirations are auscultated or secretions are visible, proceed with suctioning.References (research sources) - [1]Assessment of basic airway management among paramedic students at the University of Benin teaching hospital: A cross-sectional study.Research articleEtesin AU, Okoeguale EE. (2026) · DOI: 10.1016/j.afjem.2026.100956 ## 임상 시나리오 Unconscious Client: Airway Safety PriorityImmediate action to prevent life-threatening aspiration The highest priority for an unconscious client is ensuring a patent airway due to the loss of protective reflexes like gag and cough. This follows the ABC framework. Position the client in a side-lying (lateral recumbent/recovery) position. This uses gravity to drain secretions and prevents the tongue from falling back to obstruct the airway. It is a primary, non-invasive intervention to prevent aspiration. CautionDo not place an unconscious client supine. Suctioning is a secondary intervention; always ensure the client is first positioned to maintain airway patency. Monitor respiratory status continuously. ## 핵심 개념 - **ABC framework** — A prioritization model in nursing and resuscitation where Airway, Breathing, and Circulation are addressed in that order, with airway being the highest priority. - **Aspiration** — The inhalation of foreign material such as secretions, vomitus, or blood into the lower airways, leading to airway obstruction or pneumonia. - **Recovery position** — A side-lying position used for unconscious clients that maintains a patent airway by allowing fluids to drain from the mouth and preventing the tongue from obstructing the pharynx. - **Gag reflex** — A protective reflex that prevents material from entering the pharynx and lower airway; it is often absent or diminished in unconscious clients. - **Patent airway** — An airway that is open and clear, allowing for unobstructed passage of air into the lungs. ## 같은 주제 문제 - [A nurse is caring for an unconscious client with a traumatic brain injury. 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