A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?
Explanation & Rationale
A. Auscultate breath sounds at least every 2 hr: Immobility increases the risk of pulmonary complications such as atelectasis and pneumonia. Frequent auscultation allows early detection of abnormal lung sounds, enabling timely interventions. B. Perform range-of-motion exercises at least two to three times daily: Range-of-motion exercises help maintain joint mobility and prevent contractures. While important, they are secondary to monitoring for life-threatening respiratory complications in an immobile client. C. Apply antiembolic stockings: Antiembolic stockings help prevent venous thromboembolism in immobile clients. This intervention is important for circulation, but it is not the immediate priority compared to monitoring for respiratory complications. D. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day: Adequate hydration supports overall health and helps prevent urinary tract infections and constipation. While necessary, it is not the most urgent action to prevent immediate life-threatening complications related to immobility.