A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?

Auscultate breath sounds at least every 2 hr.

Perform range-of-motion exercises at least two to three times daily.

Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.

Apply antiembolic stockings.

Answer and Explanation

The Correct Answer is D

A. Auscultate breath sounds at least every 2 hours.

Regularly auscultating breath sounds is important for assessing respiratory status and detecting any signs of respiratory complications such as pneumonia or atelectasis. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

B. Perform range-of-motion exercises at least two to three times daily.

Range-of-motion exercises help prevent contractures and maintain joint mobility in immobile clients. While they are important for preventing musculoskeletal complications, they are not the priority action compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.

Maintaining adequate hydration is important for overall health and prevention of complications such as urinary tract infections and constipation. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

D. Apply antiembolic stockings.

The priority action for the nurse to contribute to the plan of care for an immobile client is to apply antiembolic stockings. Immobility increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE). Antiembolic stockings (also known as compression stockings or TED stockings) help prevent venous stasis and decrease the risk of blood clots forming in the lower extremities. Therefore, applying antiembolic stockings is essential in mitigating the risk of potentially life-threatening complications associated with immobility.

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Correct Answer is ["B"]

Explanation

A. 24-year-old woman with allergic rhinitis:

Likely safe to take an alpha-adrenergic decongestant as allergic rhinitis is a common indication for decongestant use in young, healthy individuals.

B. 18-year-old man with cold symptoms:

Likely safe to take an alpha-adrenergic decongestant as it's a common indication for decongestant use in young, healthy individuals.

C. 64-year-old woman with a history of heart disease:

Should avoid alpha-adrenergic decongestants due to the risk of increasing blood pressure and potentially worsening heart conditions.

D. 70-year-old woman with glaucoma:

Should avoid alpha-adrenergic decongestants due to the risk of exacerbating glaucoma by causing pupil dilation and increasing intraocular pressure.

E. 56-year-old man with prostatic hypertrophy:

Should avoid alpha-adrenergic decongestants due to the risk of worsening urinary symptoms caused by prostatic hypertrophy, such as urinary retention.

A. Administer IV morphine. B. Begin oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.

Correct Answer is B

Explanation

A. Administer IV morphine.

IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

B. Begin oxygen therapy.

The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.

C. Start an IV infusion of lactated Ringer's.

Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

D. Initiate cardiac monitoring.

Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

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A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient(s) would be able to take an alpha-adrenergic decongestant safely? (SELECT ALL THAT APPLY)

Correct Answer is ["B"]

Explanation

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

Correct Answer is B

Explanation

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