Which intervention should the nurse implement to maintain adequate hydration in an immobile patient?

Offering fluids at room temperature.

Limiting fluid intake to prevent incontinence.

Providing a straw for easier drinking.

Administering intravenous fluids continuously.

Answer and Explanation

The Correct Answer is A

Offering fluids at room temperature can enhance the patient's comfort and promote adequate hydration in immobile patients.

Incorrect choices:

b. Limiting fluid intake to prevent incontinence is not appropriate as it can lead to dehydration. Adequate hydration should be maintained, and measures to manage incontinence should be implemented separately.

c. Providing a straw for easier drinking can facilitate fluid intake, but it may not be suitable for all patients or situations. Individualized assessment and patient preference should be considered.

d. Continuous intravenous fluids may not be necessary for all immobile patients and should be based on specific indications determined by the healthcare provider. Oral intake should be encouraged unless contraindicated.

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Correct Answer is A

Explanation

Performing frequent and thorough skin assessments is essential for identifying early signs of pressure ulcers and implementing appropriate preventive measures in patients with limited mobility.

Incorrect choices:

b. Applying petroleum jelly to vulnerable areas may create a barrier but does not address the underlying issue of pressure and does not substitute for regular skin assessments and preventive measures.

c. Placing the patient on an air mattress can provide pressure redistribution, but it should be used based on individualized assessment and healthcare provider recommendations. Skin assessments remain essential.

d. Encouraging the patient to sit for prolonged periods increases the risk of pressure ulcers. Adequate repositioning and regular mobilization should be prioritized to prevent skin breakdown.

A. Encouraging the patient to remain in bed to conserve energy. B. Assisting the patient with passive range of motion exercises. C. Restricting the patient's movement to prevent falls. D. Using restraints to ensure patient safety during ambulation.

Correct Answer is B

Explanation

Assisting the patient with passive range of motion exercises promotes joint mobility and prevents contractures and muscle atrophy when the patient is unable to move independently.

Incorrect choices: a. Encouraging the patient to remain in bed perpetuates immobility and can lead to further complications such as deconditioning and reduced muscle strength.

c. Restricting the patient's movement can worsen immobility-related complications and increase the risk of falls. Appropriate interventions should be implemented to facilitate safe mobility.

d. Restraints should be avoided as much as possible and only used as a last resort to ensure patient safety. Restraints do not promote mobility and can have negative physical and psychological effects.

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Which intervention should the nurse implement to maintain adequate hydration in an immobile patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is essential to prevent pressure ulcers in a patient with limited mobility?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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