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 D
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 D
Explanation
Choice A Reason: Try to defecate at different times of the day
This statement is not advisable for clients with constipation. Regularity is key in managing constipation. Encouraging the client to try to defecate at the same time each day can help establish a routine and improve bowel regularity. The body’s natural circadian rhythms can aid in this process, making it easier to have a bowel movement at a consistent time.
Choice B Reason: Consume a low-fiber diet
A low-fiber diet is not recommended for clients with constipation. Fiber adds bulk to the stool and helps it pass more easily through the intestines. Foods high in fiber include fruits, vegetables, whole grains, and legumes. Increasing dietary fiber intake is a common and effective strategy for managing constipation. The recommended daily intake of fiber is 25 grams for women and 38 grams for men.
Choice C Reason: Reduce your daily activity
Reducing daily activity is not beneficial for managing constipation. Physical activity helps stimulate intestinal function and can promote regular bowel movements. Encouraging clients to engage in regular exercise, such as walking, swimming, or yoga, can help alleviate constipation. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic activity per week.
Choice D Reason: Increase your daily fluid intake
Increasing daily fluid intake is a key recommendation for managing constipation. Fluids help soften the stool, making it easier to pass. Water is the best choice, but other fluids like herbal teas and clear soups can also be beneficial. It is generally recommended to drink at least 8 cups (64 ounces) of water per day, though individual needs may vary based on factors such as age, sex, and activity level.
Correct Answer is B
Explanation
Choice A Reason:
This option suggests removing the mask before removing gloves. However, the correct procedure is to remove gloves first, followed by the mask, to prevent contamination from the gloves to the face.
Choice B Reason:
This is the correct answer. Medical masks should be discarded after each use to prevent contamination and ensure effectiveness. Reusing masks can lead to the spread of pathogens.
Choice C Reason:
While positioning the mask correctly is important, the statement contains an error. The flexible metal piece should be at the top of the mask, not the bottom.
Choice D Reason:
Touching the front of the mask while wearing it is incorrect as it can lead to contamination. The front of the mask is considered contaminated, and touching it can transfer pathogens to the hands.
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