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) Thrombus formation:
While immobility increases the risk of thrombus formation due to stasis of blood in the veins, hypercalcemia is not directly linked to thrombus formation. However, immobility and hypercalcemia could contribute to increased clotting risk indirectly, but renal stones are a more direct concern in this situation.

B) Pressure ulcers:
Pressure ulcers are a common concern for immobilized patients due to prolonged pressure on bony prominences. However, hypercalcemia does not directly cause or increase the risk of pressure ulcers. While immobility is a risk factor for pressure ulcers, hypercalcemia is not the primary cause for concern in this case.

C) Renal stones:
Hypercalcemia (elevated calcium levels in the blood) can lead to the formation of renal stones (kidney stones), as excess calcium is often excreted in the urine, where it can crystallize and form stones. This is the most direct and significant concern for a patient with high calcium levels. Monitoring for renal stones would be the priority action for the nurse in this case.

D) Hypostatic pneumonia:
Hypostatic pneumonia occurs due to immobility, causing mucus accumulation in the lungs and subsequent infection. While immobility is a concern for pneumonia, it is not specifically linked to hypercalcemia. The nurse should be monitoring for pneumonia in any immobilized patient, but the more immediate risk related to hypercalcemia is renal stones.

A. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. B. The nurse uses clean gloves when discontinuing a client's intravenous infusion. C. The nurse uses the client's telephone number as one form identification when administering medications to a client. D. The nurse empties client's drainable colostomy pouch when it is one third full.

Correct Answer is A

Explanation

A) The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis: This is incorrect technique. The sterile field should always be maintained, and when opening sterile trays, the nurse should open the flap away from the body to avoid contaminating the sterile field. Opening the flap toward the body increases the risk of contamination and compromises sterility, which is critical in maintaining aseptic technique during procedures.

B) The nurse uses clean gloves when discontinuing a client's intravenous infusion: Using clean gloves when discontinuing an intravenous infusion is appropriate. Clean gloves are sufficient for this non-sterile task, as the procedure does not involve direct contact with sterile body tissues or fluids. Sterile gloves are not necessary unless the task requires maintaining sterility, such as inserting a catheter.

C) The nurse uses the client's telephone number as one form of identification when administering medications to a client: This is a correct action, as the nurse is verifying the patient's identity before administering medication. It is important to use at least two identifiers (such as the patient's name and date of birth or medical record number) to ensure accurate identification, and the patient's telephone number can be an additional form of identification.

D) The nurse empties the client's drainable colostomy pouch when it is one third full: This is an appropriate action. The nurse should empty the colostomy pouch when it is one third to one half full to prevent leakage or discomfort. This action is part of proper colostomy care and helps maintain hygiene and comfort for the patient.

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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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