A nurse is caring for a hospitalized client at risk for complications of immobility. Which of the following interventions should the nurse include to prevent complications?
Instruct the client to wear a hospital gown every day, even when out of bed.
Have the client remain in bed for self-care activities.
Encourage the client to sit in the chair for all meals.
Elevate the head of the bed to 30° to 45° for medication administration.
The Correct Answer is C
Choice A Reason: Instruct the client to wear a hospital gown every day, even when out of bed
This intervention does not directly address the prevention of complications related to immobility. Wearing a hospital gown may be necessary for medical reasons, but it does not promote mobility or prevent complications such as pressure ulcers, muscle atrophy, or deep vein thrombosis (DVT). Encouraging the client to wear regular clothes when out of bed might actually promote a sense of normalcy and encourage more movement.
Choice B Reason: Have the client remain in bed for self-care activities
Keeping the client in bed for self-care activities is counterproductive in preventing complications of immobility. Prolonged bed rest can lead to muscle atrophy, decreased joint mobility, and increased risk of pressure ulcers and DVT. Encouraging the client to get out of bed and perform self-care activities while standing or sitting can help maintain muscle strength and joint flexibility.
Choice C Reason: Encourage the client to sit in the chair for all meals
Encouraging the client to sit in a chair for meals is an effective intervention to prevent complications of immobility. Sitting up helps improve digestion and respiratory function and reduces the risk of pressure ulcers by changing the pressure points on the body. It also promotes muscle activity and circulation, which are crucial in preventing DVT and maintaining overall physical health.
Choice D Reason: Elevate the head of the bed to 30° to 45° for medication administration
While elevating the head of the bed can be beneficial for certain medical conditions and for medication administration, it does not significantly contribute to preventing complications of immobility. This position can help with respiratory function and prevent aspiration during medication administration, but it does not promote overall mobility or prevent muscle atrophy and pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Monitoring for changes in urine color, such as maroon or red-colored urine, is not typically associated with peptic ulcers. These changes could indicate other conditions, such as urinary tract infections or kidney issues.
Choice B Reason:
Ecchymosis, or bruising, on the sides of the abdomen or pelvic areas is not a common symptom of peptic ulcers. This could be related to other medical conditions, such as trauma or bleeding disorders.
Choice C Reason:
This is the correct answer. Dark or black-colored stool, known as melena, can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcers. It is crucial for patients to monitor their stool color and report any changes to their healthcare provider immediately.
Choice D Reason:
Monitoring for unintentional weight gain is not directly related to peptic ulcers. While weight changes can be a sign of various health issues, they are not specific indicators of complications from peptic ulcers.
Correct Answer is A
Explanation
Choice A Reason:
Contact precautions are recommended for patients with MRSA to prevent the spread of the bacteria. This includes measures such as placing the patient in a single room, using personal protective equipment (PPE) like gowns and gloves, and ensuring proper hand hygiene. These precautions help to minimize the risk of transmission through direct or indirect contact with the patient or their environment.
Choice B Reason:
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. This is not applicable for MRSA patients, as the goal is to prevent the spread of MRSA to others, not to protect the patient from external infections.
Choice C Reason:
Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis or measles. MRSA is not transmitted through airborne particles, so this type of precaution is not appropriate.
Choice D Reason:
Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. MRSA is primarily spread through direct contact, not through respiratory droplets, making droplet precautions unnecessary.
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