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 C
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 A
Explanation
Choice A Reason: Portal of entry
The client’s mouth serves as the portal of entry in the chain of infection. The portal of entry is the route through which an infectious agent enters the host. In the case of hepatitis A, the virus enters the body through the mouth when contaminated food or water is ingested. This link is crucial in the chain of infection as it determines how the pathogen gains access to the host’s body.
Choice B Reason: Susceptible host
A susceptible host is an individual who is at risk of infection due to factors such as a weakened immune system, age, or underlying health conditions. While the client in this scenario may be a susceptible host, the mouth specifically represents the portal of entry, not the host itself.
Choice C Reason: Infectious agent
The infectious agent is the pathogen that causes the disease. In this case, the infectious agent is the hepatitis A virus. The mouth is not the infectious agent but rather the entry point for the virus into the body.
Choice D Reason: Reservoir
A reservoir is the habitat in which the infectious agent normally lives, grows, and multiplies. Common reservoirs include humans, animals, and the environment. The client’s mouth is not a reservoir but the portal of entry for the hepatitis A virus.
Correct Answer is D
Explanation
Choice A Reason:
A healthy stoma should be pink or red, not purple. A purple stoma could indicate compromised blood flow and requires immediate medical attention.
Choice B Reason:
A sigmoid colostomy typically produces formed stool because it is located in the lower part of the colon, where water absorption occurs.
Choice C Reason:
The stoma itself should not be painful after the procedure. Pain may indicate complications such as infection or improper stoma care.
Choice D Reason:
This is the correct answer. A sigmoid colostomy is usually located in the left lower abdomen, as this is where the sigmoid colon is situated.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.