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 D
Explanation
Choice A Reason: Parent who has cardiovascular disease
Having a parent with cardiovascular disease is considered a non-modifiable risk factor. This means it is related to genetic predisposition and cannot be changed or controlled by the individual. While family history is important in assessing stroke risk, it is not something that can be modified through lifestyle changes or medical interventions.
Choice B Reason: Client’s age
Age is another non-modifiable risk factor for stroke. The risk of stroke increases with age, but it is not something that can be altered. While age is an important consideration in stroke risk assessment, it is not a factor that can be modified to reduce the risk.
Choice C Reason: History of sickle cell disease
Sickle cell disease is a genetic disorder that affects the shape and function of red blood cells. It is a non-modifiable risk factor for stroke because it is inherited and cannot be changed. While managing sickle cell disease can help reduce complications, the condition itself remains a fixed risk factor.
Choice D Reason: Hypertension
Hypertension, or high blood pressure, is a significant modifiable risk factor for stroke. It can be managed and controlled through lifestyle changes such as diet, exercise, and medication. Lowering blood pressure can significantly reduce the risk of stroke, making it a key focus in stroke prevention efforts.
Correct Answer is A
Explanation
Choice A Reason:
Contact precautions are recommended for patients with MRSA to prevent the spread of the bacteria. This includes measures such as placing the patient in a single room, using personal protective equipment (PPE) like gowns and gloves, and ensuring proper hand hygiene. These precautions help to minimize the risk of transmission through direct or indirect contact with the patient or their environment.
Choice B Reason:
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. This is not applicable for MRSA patients, as the goal is to prevent the spread of MRSA to others, not to protect the patient from external infections.
Choice C Reason:
Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis or measles. MRSA is not transmitted through airborne particles, so this type of precaution is not appropriate.
Choice D Reason:
Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. MRSA is primarily spread through direct contact, not through respiratory droplets, making droplet precautions unnecessary.
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.