Which intervention is important for maintaining the safety of an immobile patient?

Correct Answer: D

Rationale: Implementing fall prevention measures is critical for an immobile patient's safety, involving tools like bed alarms, low beds, or assistance during transfers to mitigate risks in a controlled environment. Immobile patients can't walk independently, so promoting frequent movement isn't feasible and could increase danger. Physical or soft restraints, while sometimes considered, are last-resort options due to ethical and safety concerns, not primary safety strategies. Fall prevention directly addresses the vulnerability of those unable to reposition themselves, reducing injury risk a key nursing responsibility. This approach ensures a safe setting, balancing protection with patient dignity, and aligns with evidence-based practice to minimize harm in immobile populations.

Correct Answer: A

Rationale: Dry nasal passages (A) are a common complication of prolonged nasal cannula use, as unhumidified oxygen dries mucosa, causing discomfort or bleeding. Hypoventilation (B) isn't typical with low-flow devices. Hyperoxygenation (C) requires higher flows. Infection risk (D) isn't direct. Humidification prevents this, per nursing care, ensuring patient tolerance.

Correct Answer: B

Rationale: Lead poisoning is treated with chelating agents like succimer or EDTA, which bind lead in the bloodstream, facilitating its excretion and reducing toxicity a standard protocol for elevated blood levels. Gastric lavage or charcoal addresses acute ingestion, not chronic exposure common in children, while antiemetics manage symptoms, not the cause. Nurses explain this to parents, emphasizing chelation's role in reversing neurological and systemic damage, ensuring understanding of the treatment's purpose and process.

Correct Answer: A

Rationale: A soft abdomen indicates effective nasogastric suction post-bowel resection, decompressing the stomach and intestines, preventing distension or leakage at the anastomosis site. Swallowing ability, bowel sounds, or dressing condition don't directly confirm suction efficacy distension relief does. Nurses monitor this to ensure gastrointestinal rest, reducing complications like ileus or suture strain, supporting healing in a client recovering from major abdominal surgery.

Correct Answer: D

Rationale: Accurate CMV diagnosis relies on fresh specimens (e.g., urine, saliva), as the virus's viability drops quickly, critical for PCR or culture confirmation unlike stool, pregnant staff safety, or single samples. Nurses ensure prompt lab delivery, protecting immunocompromised clients from missed detection.