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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.

Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.

Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.

Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.

Correct Answer is ["3"]

Explanation

Step-by-Step Calculation:

Step 1: Determine the dose required.

Dose required = 1.5 mg

Step 2: Determine the dose available per tablet.

Dose available per tablet = 0.5 mg

Step 3: Calculate the number of tablets needed.

Number of tablets = Dose required ÷ Dose available per tablet
Number of tablets = 1.5 mg ÷ 0.5 mg/tablet

Step 4: Perform the division.

1.5 ÷ 0.5 = 3

Result: The nurse should administer 3 tablets.

Therefore, the nurse should administer 3 tablets.

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A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?

Correct Answer is B

Explanation

A nurse is preparing to administer digoxin 1.5 mg PO to a client. The amount available is digoxin 0.5 mg tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

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