The newly admitted patient has contractures of both lower extremities.
What nursing intervention should be included in this patient's plan of care?

Choice A rationale:

Maintaining the patient in a supine position during rest would not be appropriate for a client with shortness of breath. This position can worsen breathing difficulties, especially in clients with respiratory issues. It reduces lung expansion and can lead to increased work of breathing.

Choice B rationale:

Monitoring the client's oxygen saturation hourly is the appropriate intervention for a client with shortness of breath. Oxygen saturation (SpO2) levels indicate the percentage of oxygen bound to hemoglobin in the blood. Monitoring SpO2 levels helps assess the client's oxygenation status and provides crucial information about the effectiveness of respiratory interventions. Normal oxygen saturation levels typically range between 95% to 100%. Monitoring allows timely recognition of hypoxemia, enabling prompt intervention to improve oxygenation and prevent complications.

Choice C rationale:

Ambulating the client in the hall four times daily may not be suitable for a client experiencing shortness of breath, as it can exacerbate respiratory distress. Ambulation increases oxygen demand and can further compromise oxygenation in individuals struggling to breathe.

Choice D rationale:

Encouraging high protein foods during mealtime is unrelated to the immediate management of shortness of breath. While proper nutrition is essential for overall health and healing, it does not directly address the acute issue of respiratory distress.

Choice A rationale:

The nurse verifies the recipient's fax number before faxing private patient information. This action is appropriate and ensures that patient information is sent to the correct recipient, maintaining patient confidentiality and privacy. Verifying recipient information is a standard practice in healthcare settings to prevent data breaches.

Choice B rationale:

The nurse documents the patient assessment using objective data. This action is appropriate and follows evidence-based practice guidelines. Objective data are measurable and observable, providing a clear picture of the patient's condition. Objective documentation enhances communication among healthcare providers and ensures accurate representation of the patient's status.

Choice C rationale:

The nurse posts the obituary of a patient on social media. This action is highly inappropriate and unethical. It breaches patient confidentiality and privacy, violating the Health Insurance Portability and Accountability Act (HIPAA) regulations. Sharing patient information, especially sensitive details like an obituary, on social media platforms is a serious violation of privacy and can lead to legal consequences.

Choice D rationale:

The nurse discards copies of patient information into the regular trash bin. This action is inappropriate and violates patient confidentiality. Proper disposal of patient information is crucial to protect patient privacy and comply with regulations. Patient documents should be shredded or disposed of in designated secure bins to prevent unauthorized access to sensitive information.

Choice E rationale:

The nurse accesses the nurse's own health record via computer. This action is inappropriate unless there is a legitimate reason related to patient care. Accessing one's own health record without a valid purpose is a breach of patient privacy and can lead to disciplinary actions. Healthcare professionals should only access patient records when necessary for providing care and treatment.