A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)

Pressure ulcers

Contractures of the extremities

development of deep vein thrombosis

Crackles in the lungs

Polyuria

Diarrhea

Answer and Explanation

Correct Answer : A,B,C,D

A. Immobile patients are at high risk for developing pressure ulcers due to prolonged pressure on the skin, leading to tissue breakdown.

B. Contractures of the extremities can occur as a result of muscle atrophy and lack of movement in immobilized patients.

C. Immobility increases the risk of venous stasis, leading to the development of deep vein thrombosis (DVT).

D. Crackles in the lungs may result from immobility due to fluid accumulation or atelectasis, particularly in patients who are not moving or changing position frequently.

E. Polyuria is not commonly associated with immobility.

F. Diarrhea is not commonly associated with immobility.

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Correct Answer is A

Explanation

A. According to the recommended dosage range of 20 to 25 mg/kg/day for a toddler weighing 20 kg, the daily dosage should be between 400 mg (20 kg x 20 mg) and 500 mg (20 kg x 25 mg). Therefore, the prescribed dosage of 300 mg/day is below the recommended range.

B. The nurse determines the prescription is above the recommended dosage range. This is incorrect because the prescribed dosage is actually below the recommended range.

C. The nurse contacts the pharmacist to adjust the prescribed dosage. This would be an appropriate action since the prescribed dosage does not meet the recommended range, and collaboration with the pharmacist could ensure the correct dosage is administered.

D. The nurse administers the prescribed dosage. This would not be appropriate without first addressing the discrepancy between the prescribed dosage and the recommended range.

A. Inspect the nailbeds for the presence of clubbing. B. Inspect the nailbeds and mucous membranes for the presence of cyanosis. C. Palpate for areas of decreased tactile fremitus. D. Auscultate for the presence of any adventitious breath sounds.

Correct Answer is B

Explanation

A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.

B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.

C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.

D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.

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A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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