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?
Auscultate breath sounds at least every 2 hr.
Perform range-of-motion exercises at least two to three times daily.
Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
Apply antiembolic stockings.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dry mouth
Dry mouth is a common adverse effect of ipratropium (Atrovent) due to its anticholinergic properties. Anticholinergic medications can inhibit saliva production, leading to a sensation of dryness in the mouth. While uncomfortable, dry mouth tends to improve over time as the body adjusts to the medication. Patients can manage dry mouth by increasing fluid intake and practicing good oral hygiene.
B. Anxiety
Anxiety is not a common adverse effect of ipratropium (Atrovent). While some individuals may experience anxiety as a side effect of certain medications, it is not typically associated with ipratropium. If a patient experiences anxiety while taking ipratropium, it is essential to assess whether it may be related to other factors or medications and to consult a healthcare provider for appropriate management.
C. Tachycardia
Tachycardia (rapid heart rate) is not a common adverse effect of ipratropium (Atrovent). While ipratropium is an anticholinergic medication that can affect heart rate in some individuals, tachycardia is not typically reported as a common side effect. However, patients should be monitored for changes in heart rate and other cardiovascular effects while taking ipratropium, especially if they have pre-existing cardiac conditions.
D. Urine retention
Urinary retention is a potential adverse effect of ipratropium (Atrovent) due to its anticholinergic properties. Anticholinergic medications can relax the smooth muscle of the bladder, leading to difficulty emptying the bladder completely. However, urinary retention is less common with ipratropium compared to other anticholinergic medications, such as those used to treat overactive bladder. Patients experiencing urinary retention while taking ipratropium should consult their healthcare provider for further evaluation and management.
Correct Answer is A
Explanation
A. Provide humidified oxygen.
Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.
B. Perform chest physiotherapy prior to suctioning.
Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.
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