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.

Answer and Explanation

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.

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Correct Answer is ["B"]

Explanation

A. 24-year-old woman with allergic rhinitis:

Likely safe to take an alpha-adrenergic decongestant as allergic rhinitis is a common indication for decongestant use in young, healthy individuals.

B. 18-year-old man with cold symptoms:

Likely safe to take an alpha-adrenergic decongestant as it's a common indication for decongestant use in young, healthy individuals.

C. 64-year-old woman with a history of heart disease:

Should avoid alpha-adrenergic decongestants due to the risk of increasing blood pressure and potentially worsening heart conditions.

D. 70-year-old woman with glaucoma:

Should avoid alpha-adrenergic decongestants due to the risk of exacerbating glaucoma by causing pupil dilation and increasing intraocular pressure.

E. 56-year-old man with prostatic hypertrophy:

Should avoid alpha-adrenergic decongestants due to the risk of worsening urinary symptoms caused by prostatic hypertrophy, such as urinary retention.

A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Dry cough

Correct Answer is B

Explanation

A. Facial flushing

Facial flushing is not typically associated with atelectasis. Instead, it may occur in conditions such as oxygen toxicity or fever.

B. Increasing dyspnea

Atelectasis is a condition characterized by the collapse or partial collapse of a portion of the lung. Common findings in a client with atelectasis include increasing dyspnea (shortness of breath) due to impaired gas exchange and reduced lung function. As the affected lung tissue collapses, ventilation and oxygenation are compromised, leading to difficulty breathing.

C. Decreasing respiratory rate

A decreasing respiratory rate is not typically observed in a client with atelectasis. Instead, respiratory rate may increase as the body attempts to compensate for the impaired gas exchange and oxygenation resulting from lung collapse.

D. Dry cough

While coughing is a common symptom of atelectasis, it is typically associated with a productive cough rather than a dry cough. A dry cough is more commonly associated with conditions such as viral respiratory infections or allergic reactions. In atelectasis, the cough may be productive as the body attempts to clear mucus or other secretions from the affected airways.

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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?

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Naxlex Comprehensive Predictor Exams

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