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 A

Explanation

A. Encourage the client to drink 8 glasses of water a day.

This is the correct choice. Clients with COPD often have thickened respiratory secretions due to chronic inflammation and mucus production. Adequate hydration helps to keep these secretions thin, making them easier to cough up and clear from the airways. Encouraging the client to drink plenty of fluids, such as water, can assist in maintaining optimal hydration levels and promoting effective airway clearance.

B. Instruct the client to cough every 4 hours.

Instructing the client to cough on a scheduled basis, such as every 4 hours, is not appropriate for managing COPD. While coughing is important for clearing respiratory secretions, the frequency of coughing should be based on the client's individual needs and symptoms. Some clients with COPD may need to cough more frequently, while others may need to cough less often. It's important to encourage the client to cough as needed to clear secretions rather than on a predetermined schedule.

C. Provide the client with a low-protein diet.

Providing the client with a low-protein diet is not recommended for managing COPD. Adequate protein intake is important for maintaining muscle strength, including respiratory muscles, and supporting overall health. Clients with COPD may have increased energy needs due to the increased work of breathing and should be encouraged to consume a balanced diet that includes adequate protein.

D. Advise the client to lie down after eating.

Advising the client to lie down after eating is not recommended for managing COPD. Lying down after eating can increase pressure on the diaphragm and make breathing more difficult, especially for individuals with compromised lung function. It's generally recommended for individuals with COPD to remain in an upright position after eating to minimize respiratory discomfort and reduce the risk of aspiration.

A. Frequent oral hygiene is necessary B. The inhaler should be used on a PRN basis only C. Rinse and spit after inhalation of the medication D. When taking a steroid drug as well as a bronchodilator, the bronchodilator should be administered first E. Hold your breath for 10 seconds during inhalation of the medication

Correct Answer is ["A","C","D","E"]

Explanation

Correct Answers:

A. Frequent oral hygiene is necessary:Steroid inhalers can increase the risk of oral thrush and other infections, so maintaining good oral hygiene is essential to minimize this risk.

C. Rinse and spit after inhalation of the medication:Rinsing the mouth and spitting after using a steroid inhaler helps to remove residual medication and reduce the risk of developing oral thrush.

D. When taking a steroid drug as well as a bronchodilator, the bronchodilator should be administered first:Administering a bronchodilator first helps open the airways, allowing the steroid medication to reach deeper into the lungs for more effective treatment.

E. Hold your breath for 10 seconds during inhalation of the medication:Holding the breath allows for better medication absorption in the lungs.

Incorrect Answer:

B. The inhaler should be used on a PRN basis only:Steroid inhalers are typically used on a regular schedule for long-term control of asthma or other respiratory conditions, rather than on a PRN (as needed) basis. PRN use is more applicable to rescue inhalers, like short-acting bronchodilators.

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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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