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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Water heater temperature 54.4°C (130" F) B. Bathtub with rails C. Raised toilet seats D. Electric cords behind the furniture E. Throw rugs

Correct Answer is ["A","D"]

Explanation

A) Water heater temperature 54.4°C (130°F):
A water heater temperature of 130°F is a safety risk for older adults. At this temperature, there is a higher risk of burns, especially for individuals who may have impaired sensitivity to heat. It is recommended to set the water heater temperature at 120°F to prevent accidental burns.

B) Bathtub with rails:
The presence of bathtub rails is a safety feature, not a risk. They help provide support and stability for older adults when entering or exiting the bathtub, reducing the risk of falls. This finding should not be considered a safety risk.

C) Raised toilet seats:
Raised toilet seats are beneficial for individuals with mobility limitations, as they provide extra height and make it easier for older adults to sit down and stand up. This modification can actually help prevent falls and should not be considered a safety risk.

D) Electric cords behind the furniture:
Electric cords placed behind furniture pose a tripping hazard, especially for older adults who may have impaired vision or mobility. These cords can be a safety risk as they increase the likelihood of falls. It is essential to ensure that cords are properly secured and not in pathways or areas where they can be tripped over.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the first?

Correct Answer is D

Explanation

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse Identify as safety risk for the client? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

A client smoking in his bathroom has dropped a cigarette butt into wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care?

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's Infection?

A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding Indicates successful goal achievement?

A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients: Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching?

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night. Which of the following actions should the nurse take?