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

Choice A Reason:

Place suction equipment at the bedside is incorrect. While having suction equipment available is important for emergency situations, it does not directly prevent postoperative pulmonary complications. Suction equipment is used to clear the airway if the client has difficulty breathing or if there is an obstruction.

Choice B Reason:

Administer a prophylactic expectorant is incorrect. Prophylactic expectorants can help in managing secretions, but they are not the primary intervention for preventing postoperative pulmonary complications. The main goal is to promote lung expansion and prevent atelectasis.

Choice C Reason:

Encourage the use of an incentive spirometer is correct. Using an incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis and other postoperative pulmonary complications. It is a key intervention in postoperative care to maintain optimal lung function.

Choice D Reason:

Perform range of motion exercises is incorrect. While range of motion exercises are important for preventing musculoskeletal complications and promoting circulation, they do not directly prevent pulmonary complications. The focus for pulmonary health is on lung expansion and clearing secretions.

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.