Author Question: The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical ... (Read 114 times)

CORALGRILL2014 · **on:** Jul 22, 2018

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment. When assessing the respiratory system, the nurse should

a. Assess the patient at least every 4 hours.
b. Inspect chest wall movements during the expiratory cycle only.
c. Auscultate the entire lung region to assess lung sounds.
d. Focus auscultation on the upper lung fields.

Question 2

The nurse is assessing body alignment for a patient who is immobilized. To do this, the nurse must

a. Place the patient in the supine position.
b. Remove the pillow from under the patient's head.
c. Insert positioning supports to help the patient.
d. Place the patient in a lateral position.

Ashley I · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

Answer to Question 2

D
Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning support from the bed, except for the pillow under the head.