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. Mixing medications can alter their effectiveness and increase the risk of tube blockage. Each medication should be administered separately.
B. Flushing the NG tube with 30 mL of water after administering medications is important to ensure that the medications are cleared from the tube and absorbed properly by the patient. This also helps to prevent tube occlusion.
C. Diluting medications may not be necessary for all liquid medications, and it depends on the specific medication's guidelines. Each medication should be administered as directed.
D. The head of the bed should be elevated during and after medication administration to prevent aspiration. Keeping it flat is not recommended.
Correct Answer is C
Explanation
A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.
B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.
C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.
D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.