A nurse is caring for a client who is on bed rest.
The nurse should recognize that which of the following findings is a complication of immobility?

Swollen area on calf.

Increased blood pressure.

Decreased serum calcium levels.

Urinary frequency.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.

Choice B rationale:

Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.

Choice C rationale:

Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.

Choice D rationale:

Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.

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Correct Answer is A

Explanation

A. Lift the penis so that it is perpendicular to the client's body. B. Cleanse the tip of the penis in a side-to-side motion. C. Pick up the catheter 13 cm (5 in) from its tip. D. Inflate the catheter balloon before insertion.

Correct Answer is A

Explanation

The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.

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A nurse is caring for a client who is on bed rest.The nurse should recognize that which of the following findings is a complication of immobility?

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A nurse is caring for a client who is on bed rest.
The nurse should recognize that which of the following findings is a complication of immobility?