A nurse is caring for an immobile patient. What is the most ...

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A nurse is caring for an immobile patient. What is the most appropriate nursing intervention to implement?
 
  a. Turn the patient every 4 hours.
  b. Apply an abdominal binder while the patient is lying in bed.
  c. Encourage the regular use of incentive spirometry while awake.
  d. Maintain the patient's maximum fluid intake of 1000 mL daily.

Question 2

Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?
 
  a. Maintain complete bed rest.
  b. Place tight clothing on the legs and waist.
  c. Put pillows under the knees.
  d. Position properly with use of antiembolic stockings.

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Answer to Question 1

C
You can also promote lung expansion through regular deep breathing exercises, use of an incentive spirometer, and forceful coughing. Changing the position of the patient at least every 2 hours, not 4, allows the dependent lung regions to re-expand, maintains the elastic recoil property of the lungs, and clears the dependent lung regions of pulmonary secretions. Your assessment will determine if patients need more frequent position changes. An application of an abdominal binder will restrict chest expansion. Make sure that the immobile patient has a fluid intake of at least 2000 mL per day, if not contraindicated, to help keep mucociliary clearance intact.

Answer to Question 2

D
Proper positioning used with other therapies (e.g., anticoagulants and antiembolic stockings) helps reduce thrombus formation. When positioning patients, use caution to prevent pressure on the posterior knee and deep veins in the lower extremities. Teach patients to avoid crossing the legs, sitting for prolonged periods of time, wearing tight clothing that constricts the legs or waist, putting pillows under the knees, and massaging the legs. Complete bed rest increases the chance for thrombus formation.