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. Each of movement is repeated 5 times by the patient B. Each movement is moved just to the point of resistance by the nurse C. Each movement is completed quickly and smoothly by the nurse D. Each movement is performed until the patient’s reports pain

Correct Answer is B

Explanation

A) Each movement is repeated 5 times by the patient: While active range-of-motion (ROM) exercises often involve repetition, the key goal of passive ROM exercises (when the nurse is assisting the patient) is not to have the patient repeat movements. Instead, the nurse should ensure the patient’s joints are moved gently to their fullest range without causing discomfort or damage. Repeating movements a specific number of times isn't a required approach for passive ROM.

B) Each movement is moved just to the point of resistance by the nurse: This technique is the most appropriate when performing passive ROM exercises. The nurse should gently move the joint through its range of motion and stop at the point where resistance is felt, but without pushing into pain or forcing movement beyond the joint’s natural limits. This approach helps prevent injury while still providing the necessary mobility and flexibility.

C) Each movement is completed quickly and smoothly by the nurse: While the movement should be smooth, it should never be rushed or performed quickly, as that can cause strain or discomfort. ROM exercises should be done slowly and deliberately to avoid injury and to allow the joints to move through their full range of motion without abrupt movements. Quick motions could increase the risk of joint or muscle injury.

D) Each movement is performed until the patient reports pain: ROM exercises should be performed gently and within the range that does not cause pain. The goal is to maintain joint flexibility and prevent contractures, not to push the patient into pain. If the patient reports pain, the nurse should stop immediately to avoid injury and reassess the approach to ROM exercises. Pain should never be a target for achieving range of motion.

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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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