A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?
Applying compression stockings
Raising all side rails
Inserting a urinary catheter
Using friction-reducing devices
The Correct Answer is A
Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.
Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.
Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.
Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Prolonging the life of a client is not the primary focus of palliative care. While palliative care can sometimes extend life by improving overall well-being and reducing stress, its main goal is to enhance the quality of life by managing symptoms and providing comfort12. Palliative care is not primarily aimed at life extension but rather at ensuring that patients live as well as possible despite their illness.
Choice B Reason:
Controlling symptoms and providing comfort is the core focus of palliative care. This type of care aims to alleviate pain and other distressing symptoms, such as nausea, shortness of breath, and fatigue12. Palliative care also addresses emotional, social, and spiritual needs, helping patients and their families cope with the challenges of serious illness. By focusing on comfort and quality of life, palliative care supports patients in living as fully as possible.
Choice C Reason:
Replacing other treatments for an illness is not the focus of palliative care. Palliative care is designed to complement, not replace, other medical treatments12. It can be provided alongside curative or life-prolonging treatments, offering additional support to manage symptoms and improve quality of life. The goal is to provide a holistic approach to care that addresses all aspects of a patient’s well-being.
Choice D Reason:
Curing a serious illness is not the aim of palliative care. Palliative care is appropriate for patients at any stage of a serious illness, whether or not a cure is possible12. Its primary focus is on symptom management, comfort, and quality of life, rather than on curing the illness. This approach helps patients and their families navigate the complexities of serious health conditions with greater ease and support.
Correct Answer is A
Explanation
Choice A Reason:
Age dose of pain medication refers to adjusting the dosage of pain medication based on the client’s age. Elderly clients often have different pharmacokinetics and pharmacodynamics compared to younger individuals, which means they may require lower doses of medication to achieve the same effect. This adjustment helps to prevent overmedication and potential side effects, ensuring safe and effective pain management for elderly clients.
Choice B Reason:
Correct method of administering your own pain medication is important for clients who are capable of self-administering their medication. However, this choice does not directly address the issue of balance deficit and the need for an assistive device. While proper medication administration is crucial, it is not the primary concern in this scenario.
Choice C Reason:
Operator can push the PCA button for you if you are asleep is not an appropriate practice. Patient-controlled analgesia (PCA) is designed to allow clients to self-administer pain medication as needed. Allowing someone else to push the button can lead to overmedication and potential complications. This choice does not address the need for an assistive device for balance deficit.
Choice D Reason:
The pain medication is delivered at your nose is not a standard method of pain medication administration. This choice is incorrect and does not relate to the client’s need for an assistive device for balance deficit. Pain medication is typically administered orally, intravenously, or through other appropriate routes, but not through the nose.
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