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 D

Explanation

A) Socioeconomic factors:
Socioeconomic factors, such as income, education, and employment status, are considered external variables that influence a patient's health. These factors impact access to resources and healthcare, but they are not internal variables. Internal factors relate to personal perceptions, behaviors, and beliefs that the patient has regarding their health.

B) Family practices:
Family practices also fall under external variables. These include the health behaviors, habits, and routines practiced by the family, which can influence a patient’s health but are not internal to the individual. The nurse should assess how family practices affect health but not as internal variables.

C) Cultural background:
Cultural background is another external variable that can influence health practices, beliefs, and behaviors. It shapes how patients perceive illness, health care, and healing. While important to assess for understanding a patient's worldview, it does not fall under the category of internal variables.

D) Perception of functioning:
Perception of functioning is an internal variable because it reflects how the patient views their own health status and capabilities. This includes their sense of well-being, physical limitations, and emotional health. A patient’s perception of their functioning can directly impact their decision-making and actions related to their health, and it is essential for the nurse to assess this to guide care effectively.

A. Assess the client every 4 hr. B. Keep the client's room dark at night. C. Teach the client to use the call light. D. Keep the client's bed in the lowest position E. Place a fall-risk identification band on the client's wrist

Correct Answer is ["C","D","E"]

Explanation

A) Assess the client every 4 hr: Assessing the client every 4 hours is not frequent enough, especially for patients at high risk for falls. A more frequent assessment, such as every 1-2 hours or as clinically appropriate, is recommended to monitor the patient's safety and to ensure timely intervention if needed.

B) Keep the client's room dark at night: Keeping the room dark at night would increase the risk of falls. Adequate lighting should be provided to ensure the client can safely navigate the room and call for assistance if necessary. Nightlights or low-level lighting are often used to prevent accidents in the dark.

C) Teach the client to use the call light: This is an essential action to prevent falls. Teaching the client to use the call light ensures that they can summon help if they need assistance to get out of bed or move around, reducing the risk of attempting to move independently and falling.

D) Keep the client's bed in the lowest position: This is a key safety measure. Keeping the bed in the lowest position reduces the risk of injury if the client attempts to get out of bed independently or if they fall. It also makes it easier for the client to safely exit the bed with assistance.

E) Place a fall-risk identification band on the client's wrist: This is an important action to alert all healthcare staff about the client's fall risk. A fall-risk identification band helps ensure that everyone involved in the patient's care is aware of the need for extra precautions to prevent falls.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

Correct Answer is D

Explanation

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Correct Answer is ["C","D","E"]

Explanation

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