The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take assessing, the respiratory system?

Auscultate the entire lung region to assess lung sounds

Assess the patient at least every 4 hours.

Inspect chest wall movements primarily during the expiratory cycle

Focus auscultation on the upper lung fields

Answer and Explanation

The Correct Answer is A

A) Auscultate the entire lung region to assess lung sounds: This is the most comprehensive action. To properly assess for respiratory complications related to immobility, the nurse should auscultate all lung fields (anterior, posterior, and lateral) to detect any abnormal lung sounds such as crackles, wheezes, or decreased breath sounds. This thorough assessment helps to identify early signs of respiratory compromise, such as atelectasis or pneumonia, which are common complications of immobility.
B) Assess the patient at least every 4 hours: While regular assessment is important, the frequency of assessment should be tailored to the patient’s condition and risk factors. In critically ill or immobile patients, more frequent assessments (every 1-2 hours) may be necessary to detect changes in respiratory status early. A minimum of 4 hours may be too long between assessments for patients at risk for respiratory complications.

C) Inspect chest wall movements primarily during the expiratory cycle: The nurse should assess both the inspiratory and expiratory phases of chest wall movement, not focus solely on expiration. Inspecting both phases allows the nurse to evaluate whether the patient is having difficulty with inspiration or expiration, both of which are important indicators of respiratory function. Focusing only on expiration might miss other critical issues like shallow or labored breathing during inspiration.

D) Focus auscultation on the upper lung fields: While it is important to auscultate the upper lung fields, respiratory complications related to immobility, such as atelectasis, are more commonly observed in the lower lung fields due to gravity. Auscultating only the upper lung fields could miss abnormalities in the lower parts of the lungs, where secretions may accumulate more easily in immobile patients. Full lung auscultation is necessary for an accurate assessment.

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Correct Answer is B

Explanation

A) Changing the client's bed linens each day:
While changing bed linens regularly is important for maintaining cleanliness and preventing the spread of infection, it alone is not the most effective strategy to prevent transmission of infection. Hand hygiene before, during, and after contact with the client is a more crucial step to break the chain of infection and prevent transmission.

B) Performing hand hygiene before, during, and after direct contact with the client:
Hand hygiene is the most effective and critical strategy for preventing the transmission of infections. By performing proper hand hygiene at appropriate times, the nurse reduces the risk of spreading pathogens from the patient to themselves, other patients, and the environment. This is a key practice in infection control and is widely recognized as one of the best preventive measures.

C) Placing the client in a room with positive pressure airflow:
Positive pressure airflow is used for clients who have weakened immune systems (e.g., those with neutropenia) to protect them from infections. However, this is not the appropriate strategy for a client with an active infection, as it could potentially spread infectious agents in the environment. Infections typically require isolation with appropriate precautions like contact or droplet precautions rather than positive pressure airflow.

D) Encouraging the client to consume a high-protein diet:
Encouraging a high-protein diet is important for supporting the client's immune function and overall recovery. However, it does not directly prevent the transmission of the infection. The priority in infection control is using strategies like hand hygiene and proper isolation procedures to prevent the spread of the infection.

A. Complete an incident report. B. Request the risk manager obtain consent for HIV testing from the client. C. Consent to postexposure treatment with antiretroviral medications. D. Wash the site of injury with soap and water.

Correct Answer is D

Explanation

A) Complete an incident report: While it is essential to complete an incident report, this is not the first action to take. Completing the report documents the event but should come after immediate steps are taken to prevent further complications and ensure the nurse's safety. The priority is to first address the injury and ensure the site is properly cleaned.

B) Request the risk manager obtain consent for HIV testing from the client: Requesting consent for HIV testing from the client is important, but it is not the first priority. The immediate action should focus on treating the injury and reducing the risk of infection. Once the injury is addressed, the next step is to assess the potential for exposure and initiate testing or other preventive measures.
C) Consent to postexposure treatment with antiretroviral medications: Postexposure prophylaxis (PEP) with antiretroviral medications is an important step after a needle-stick injury, especially if the source patient has an unknown HIV status or is known to be HIV-positive. However, this step should come after immediate wound care and before initiating any further testing or preventive treatments.

D) Wash the site of injury with soap and water: The first and most crucial step after a needle-stick injury is to immediately wash the wound thoroughly with soap and water. This action helps reduce the risk of infection by removing any potential contaminants from the needle or the environment. After cleaning the wound, the nurse should then proceed with further steps, such as reporting the incident, obtaining consent for HIV testing, and considering PEP if indicated.

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The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take assessing, the respiratory system?

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