A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

A) Auscultate the entire lung region to assess lung sounds: This is the most comprehensive action. To properly assess for respiratory complications related to immobility, the nurse should auscultate all lung fields (anterior, posterior, and lateral) to detect any abnormal lung sounds such as crackles, wheezes, or decreased breath sounds. This thorough assessment helps to identify early signs of respiratory compromise, such as atelectasis or pneumonia, which are common complications of immobility.
B) Assess the patient at least every 4 hours: While regular assessment is important, the frequency of assessment should be tailored to the patient’s condition and risk factors. In critically ill or immobile patients, more frequent assessments (every 1-2 hours) may be necessary to detect changes in respiratory status early. A minimum of 4 hours may be too long between assessments for patients at risk for respiratory complications.

C) Inspect chest wall movements primarily during the expiratory cycle: The nurse should assess both the inspiratory and expiratory phases of chest wall movement, not focus solely on expiration. Inspecting both phases allows the nurse to evaluate whether the patient is having difficulty with inspiration or expiration, both of which are important indicators of respiratory function. Focusing only on expiration might miss other critical issues like shallow or labored breathing during inspiration.

D) Focus auscultation on the upper lung fields: While it is important to auscultate the upper lung fields, respiratory complications related to immobility, such as atelectasis, are more commonly observed in the lower lung fields due to gravity. Auscultating only the upper lung fields could miss abnormalities in the lower parts of the lungs, where secretions may accumulate more easily in immobile patients. Full lung auscultation is necessary for an accurate assessment.

A) Four wheel walker: While a four-wheel walker provides excellent support and stability for clients with significant mobility limitations, it is not always the best choice for someone who occasionally loses balance. It can be bulky and difficult to maneuver in tight spaces, and it may not provide as much support for clients who need only occasional assistance with balance. A gait belt allows for more hands-on assistance when needed.

B) Gait belt: A gait belt is the most appropriate device to use when assisting a client who occasionally loses balance. It allows the nurse to provide hands-on support and maintain the client’s safety during ambulation. The gait belt provides a secure hold, enabling the nurse to assist the client in regaining balance quickly, preventing falls if the client starts to lose their stability.

C) Jacket harness: A jacket harness is typically used in more severe cases of balance loss or in situations where the client has significant mobility impairments. While it provides more overall support, it may not be necessary for a client who only occasionally loses balance. It can also be more cumbersome than a gait belt for helping with short, occasional ambulation.

D) Cane: A cane is helpful for clients who need mild to moderate support while walking, but it might not offer enough stability for a client who occasionally loses balance. A cane may provide support in some cases, but using a gait belt would be more effective for safely supporting and guiding the client during ambulation.