Difficulty: Medium
Average Score: 90%
Simulated
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
Correct answer
B
Rationale
Placing the client in a side-lying position with the head elevated prevents aspiration and maintains airway patency, critical for a client with altered consciousness.