The nurse is assessing the patient for respiratory complications ...

[serike]

The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system?
 
  a. Inspect chest wall movements primarily during the expiratory cycle.
  b. Auscultate the entire lung region to assess lung sounds.
  c. Focus auscultation on the upper lung fields.
  d. Assess the patient at least every 4 hours.

Question 2

A nurse is assessing the skin of an immobilized patient. What will the nurse do?
 
  a. Assess the skin every 4 hours.
  b. Limit the amount of fluid intake.
  c. Use a standardized tool such as the Braden Scale.
  d. Have special times for inspection so as to not interrupt routine care.

[connor417]

Answer to Question 1

ANS: B
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

ANS: C
Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care.