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 A
Explanation
A. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.
B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.
C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.
D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.
Correct Answer is ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.