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Limiting communication with healthcare providers can increase risk, as older adults may not receive necessary guidance or early detection of health issues.

Avoiding home safety assessments increases the risk of falls or accidents; assessing the home environment is crucial for safety.

Encouraging isolation can lead to social, emotional, and cognitive decline, which negatively impacts safety and well-being.

Tightening abdominal muscles helps stabilize the nurse’s core but is performed after proper bed height and positioning are established.

Placing feet in line with shoulders is part of body mechanics during the move, but it follows ensuring the work surface is at the correct height.

Pivoting the feet in the direction of the move helps maintain spinal alignment and prevent twisting injuries, but it occurs during the actual repositioning, not as the first step.

Elevating the arm above heart level can cause a falsely low blood pressure reading; the arm should be at heart level.

The cuff should be placed 2–3 cm (about 1 inch) above the antecubital space, not 5 cm, to ensure accurate measurement.

The cuff should cover about 80% of the upper arm circumference, not 50%; using a cuff that is too small or too large can distort the measurement.

Waiting only 10 seconds may not allow the pulse oximeter to stabilize; readings typically stabilize within 30–60 seconds.

Placing the sensor on the same extremity as a blood pressure cuff can produce inaccurate readings due to intermittent compression.

The sensor does not need to be relocated every 8 hours unless there are concerns about skin integrity, pressure, or circulation.

Restlessness is a common early sign of hypoxia. If the client remains restless despite supplemental oxygen, it suggests that oxygenation has not yet normalized.

A respiratory rate of 28/min is above the normal adult range (12–20/min), indicating that the client may still be experiencing respiratory distress or inadequate oxygenation.

A heart rate of 110/min (tachycardia) may represent a compensatory response to hypoxia. If heart rate remains elevated, it may indicate that the oxygen therapy has not fully stabilized the client’s oxygenation.

PROM does not significantly affect bone density, which is more influenced by weight-bearing activity.

PROM does not increase muscle strength, as the client’s muscles are not actively contracting during the movement.

PROM does not increase muscle mass, since muscle growth requires active resistance or exercise.

Bladder outlet obstruction is a structural or mechanical issue, not directly caused by immobility.

Protein in the urine (proteinuria) is more indicative of kidney damage or disease rather than retention from immobility.

Neurogenic bladder is related to nerve dysfunction, not solely immobility, although immobility may exacerbate voiding difficulties. Monitoring for infection is more immediate and relevant.

Mineral oil may be used for constipation, but it is not the first-line intervention due to potential side effects, such as interference with absorption of fat-soluble vitamins.

A low-fiber diet would likely worsen constipation, as fiber adds bulk to stool and stimulates peristalsis.

While cold fluids may have a mild stimulant effect, the overall priority is ensuring adequate hydration to prevent constipation.

Staying close to the ground is important when moving through smoke-filled areas, but it is not the first action when identifying the source of smoke.

Wrapping clients in blankets may help during evacuation but does not address immediate containment of the fire.

Walking to a safe area is important for personal safety, but first, the fire must be contained to protect others and prevent escalation.