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 A
Explanation
Choice A Reason: WBC Count 22,000/mm³
A white blood cell (WBC) count of 22,000/mm³ is significantly higher than the normal range, which is typically between 4,000 and 11,000/mm³. An elevated WBC count, known as leukocytosis, often indicates the presence of an infection as the body produces more white blood cells to fight off pathogens. This elevated count can also be seen in other conditions such as inflammation, stress, or bone marrow disorders, but it is a strong indicator of infection.
Choice B Reason: Hgb 15 g/dL
Hemoglobin (Hgb) levels of 15 g/dL fall within the normal range for adults, which is generally 13.8 to 17.2 g/dL for males and 12.1 to 15.1 g/dL for females. Normal hemoglobin levels indicate that the blood’s oxygen-carrying capacity is adequate and do not specifically point to an infection.
Choice C Reason: Creatine kinase 75 units/L
Creatine kinase (CK) levels of 75 units/L are within the normal range, which is typically 24 to 204 U/L. CK is an enzyme found in the heart, brain, and skeletal muscle, and elevated levels can indicate muscle damage, myocardial infarction, or other conditions affecting these tissues. However, normal CK levels do not indicate the presence of an infection.
Choice D Reason: Platelet count 200,000/mm³
A platelet count of 200,000/mm³ is within the normal range, which is generally between 150,000 and 450,000 platelets per microliter of blood. Platelets are involved in blood clotting, and normal levels do not indicate an infection. Abnormal platelet counts can be associated with bleeding disorders or thrombosis, but a normal count does not suggest an infection.
Correct Answer is C
Explanation
Choice A Reason:
Encouraging the client to bear down is not an appropriate response to abdominal cramps during an enema. Bearing down can increase discomfort and does not address the underlying cause of the cramps.
Choice B Reason:
Stopping the enema and documenting that the client did not tolerate the procedure is not the best initial action. While it is important to document the client’s response, there are other steps that can be taken to alleviate the discomfort before stopping the procedure entirely.
Choice C Reason:
This is the correct answer. Lowering the height of the solution container will reduce the flow rate of the enema solution, which can help alleviate abdominal cramps. A slower flow rate is less likely to cause cramping and discomfort.
Choice D Reason:
Allowing the client to expel some fluid before continuing can help relieve discomfort, but it is not the most immediate or effective action. Adjusting the flow rate by lowering the height of the solution container is a more direct way to address the issue.
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