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 C
Explanation
A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.
B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.
C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.
D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.
Correct Answer is A
Explanation
A. Requesting a prescription for an oral formulation of the medication is the appropriate action, as sublingual medications are designed to dissolve under the tongue and bypass the gastrointestinal tract, which is not feasible with an NG tube in place.
B. Administering the medication under the client's tongue is incorrect because the NG tube prevents effective absorption through the sublingual route.
C. Dissolving the medication in water and giving it through the NG tube defeats the purpose of sublingual administration and may not provide the desired therapeutic effect.
D. Administering the crushed medication through the NG tube is inappropriate for sublingual medications, as this can alter the medication's pharmacokinetics and effectiveness.