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 C

Explanation

A) Try to do as much as possible for the patient:
While it's important to provide support to a patient with osteoporosis, especially when they are at risk of fractures, the nurse should focus on empowering the patient to maintain as much independence as possible. Over-involvement in their care may limit their ability to maintain or improve mobility and self-care abilities. The priority is addressing nutritional needs and bone health.

B) Encourage dairy products:
While dairy products are an excellent source of calcium, this approach is not suitable for a patient with lactose intolerance. Consuming dairy could lead to discomfort and digestive issues such as bloating, cramps, and diarrhea, which can worsen the patient's symptoms. Alternative sources of calcium should be recommended instead.

C) Monitor intake of calcium:
This is the most appropriate intervention. Monitoring the patient's calcium intake is crucial for individuals with osteoporosis to help strengthen bones and prevent fractures. The nurse can recommend calcium-rich foods that are lactose-free, such as fortified plant-based milks, leafy green vegetables, and fortified cereals. Calcium supplements may also be necessary to meet the daily requirements.

D) Increase intake of caffeinated drinks:
Increasing caffeinated drinks is not advisable for a patient with osteoporosis, as excessive caffeine consumption can interfere with calcium absorption and contribute to bone loss. It is best to limit caffeine intake and focus on promoting good nutritional habits to support bone health.

A. Return any fresh linen not used for a client to the linen supply: B. Tie linen bags securely at the top. C. Fili linen bags with as much soiled linen as possible: D. Use double bagging to remove soiled linen from the client's room.

Correct Answer is B

Explanation

A) Return any fresh linen not used for a client to the linen supply: Fresh linen that has been placed on a client’s bed but not used should not be returned to the linen supply. This is to prevent cross-contamination. Once linen is brought into a patient’s room, it should be considered contaminated, even if it was not used, and should be discarded properly.

B) Tie linen bags securely at the top: This is the correct action. When disposing of soiled linens, tying the linen bag securely helps to prevent the spread of pathogens and minimizes the risk of contamination. It also keeps the environment clean and safe for both staff and patients.

C) Fill linen bags with as much soiled linen as possible: Linen bags should not be overfilled. Overfilling bags can make them difficult to handle and can increase the risk of exposure to contaminants. Bags should be filled to a safe and manageable level to ensure proper handling and safety when transporting soiled linens.

D) Use double bagging to remove soiled linen from the client's room: Double bagging is typically not necessary unless there is a significant risk of contamination, such as with highly infectious material. Standard practice is to use a single, securely tied bag. Double bagging can create unnecessary waste and complicate disposal procedures unless specifically indicated by the situation or facility protocols.

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