A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Applying compression stockings

Raising all side rails

Inserting a urinary catheter

Using friction-reducing devices

Answer and Explanation

The Correct Answer is A

Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.

Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.

Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.

Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.

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Correct Answer is C

Explanation

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

A. Starting chest compressions B. Obtaining a central line C. Completing a comprehensive assessment D. Providing rescue breathing

Correct Answer is A

Explanation

Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.

Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.

Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.

Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.

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A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

Correct Answer is C

Explanation

A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

Correct Answer is A

Explanation

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