A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?

First, we need to find out how many milligrams (mg) are in 1 milliliter (mL) of the available diphenhydramine solution:

12.5 mg/5 mL

To find out how many milligrams are in 1 mL, we divide the total milligrams by the total milliliters:

12.5 mg ÷ 5 mL = 2.5 mg/mL

Now that we know the concentration of diphenhydramine is 2.5 mg/mL, we can calculate the dose needed for the order of 25 mg:

25 mg ÷ 2.5 mg/mL = 10 mL

A. Auscultate breath sounds at least every 2 hours.

Regularly auscultating breath sounds is important for assessing respiratory status and detecting any signs of respiratory complications such as pneumonia or atelectasis. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

B. Perform range-of-motion exercises at least two to three times daily.

Range-of-motion exercises help prevent contractures and maintain joint mobility in immobile clients. While they are important for preventing musculoskeletal complications, they are not the priority action compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.

Maintaining adequate hydration is important for overall health and prevention of complications such as urinary tract infections and constipation. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

D. Apply antiembolic stockings.

The priority action for the nurse to contribute to the plan of care for an immobile client is to apply antiembolic stockings. Immobility increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE). Antiembolic stockings (also known as compression stockings or TED stockings) help prevent venous stasis and decrease the risk of blood clots forming in the lower extremities. Therefore, applying antiembolic stockings is essential in mitigating the risk of potentially life-threatening complications associated with immobility.