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 D
Explanation
A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.
Correct Answer is B
Explanation
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.