A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?
Perform range-of-motion (ROM) exercises at least two to three times daily.
Auscultate breath sounds at least every 2 hr.
Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
Apply anti-embolic stockings.
The Correct Answer is B
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.
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Correct Answer is B
Explanation
A. While a high-protein diet can support healing, it does not directly prevent the transmission of infection.
B. Performing hand hygiene before, during, and after direct contact with the client is crucial to prevent the transmission of pathogens and is a fundamental practice in infection control.
C. Positive-pressure airflow is used for clients who are immunocompromised to prevent them from contracting infections, not for clients with existing infections.
D. Changing bed linens daily can contribute to infection control but is not as effective as hand hygiene in preventing transmission.
Correct Answer is D
Explanation
A. The nurse can provide information about the procedure and assist the client in understanding the consent form, but they are not responsible for obtaining informed consent.
B. The surgical suite nurse assists in the surgical environment but does not have the authority to obtain consent.
C. The anesthesiologist discusses the anesthesia involved but does not obtain consent for the surgery itself.
D. The surgeon is responsible for obtaining informed consent, as they must explain the procedure, risks, and benefits to the client before the client can make an informed decision.