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 ["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.

A. Ensure four fingers fit under the restraints to prevent constriction. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Anticipate removing the restraints every 4 hr.

Correct Answer is C

Explanation

A) Ensure four fingers fit under the restraints to prevent constriction: While it is important to ensure that restraints are not too tight, the general recommendation is to allow enough room for two fingers, not four. The primary goal is to prevent impaired circulation and nerve damage while also ensuring that the restraint is secure enough to prevent the patient from causing harm to themselves or others. Four fingers may be too loose and could lead to unnecessary movement.

B) Secure the restraints to the lowest bar of the side rail: Restraints should never be secured to a side rail, as the side rails may move and cause the restraint to become tight, which could lead to injury. Restraints should be tied to a fixed part of the bed frame to prevent them from becoming loose or causing undue pressure. Securing to side rails can increase the risk of harm.

C) Secure the restraints using a quick-release tie: This is the correct action. The nurse should always use a quick-release tie to ensure that the restraints can be removed immediately if needed. Quick-release ties allow for rapid removal in case of emergency, reducing the risk of injury or distress to the patient. This ensures safety while still maintaining control over the restraint application.

D) Anticipate removing the restraints every 4 hr: While restraints should be removed periodically to check the skin, circulation, and comfort of the patient, the time frame for removal varies depending on the patient's condition and the facility's protocol. Restraints should be removed more frequently than every 4 hours, if possible, to ensure the patient’s safety and comfort. The nurse should follow the facility's specific protocol for restraint monitoring and removal.

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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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