Assisting the patient with passive range of motion exercises promotes joint mobility and prevents contractures and muscle atrophy when the patient is unable to move independently.

Incorrect choices: a. Encouraging the patient to remain in bed perpetuates immobility and can lead to further complications such as deconditioning and reduced muscle strength.

c. Restricting the patient's movement can worsen immobility-related complications and increase the risk of falls. Appropriate interventions should be implemented to facilitate safe mobility.

d. Restraints should be avoided as much as possible and only used as a last resort to ensure patient safety. Restraints do not promote mobility and can have negative physical and psychological effects.

Supporting bony prominences with pillows or foam pads helps distribute pressure and reduces the risk of pressure ulcers in patients with limited mobility.

Incorrect choices:

a. Placing the patient in a prone position for extended periods increases the risk of pressure ulcers, especially on the anterior aspects of the body.

b. Elevating the head of the bed to 90 degrees can lead to shearing forces and increase the risk of pressure ulcers.

d. Encouraging the patient to sit in a chair for long periods without adequate repositioning can also increase the risk of pressure ulcers.

Patients who undergo surgery are at an increased risk for developing deep vein thrombosis (DVT) due to the immobility associated with the postoperative period.

Incorrect choices:

a. While hypertension is a risk factor for cardiovascular diseases, it does not increase the risk of DVT specifically.

c. Regular exercise is a protective factor against DVT, as it promotes circulation and venous return.

d. Diabetes is a risk factor for peripheral vascular disease, but it does not directly increase the risk of DVT.

Encouraging deep breathing and coughing techniques helps prevent respiratory complications such as atelectasis and pneumonia in patients with impaired mobility.

Incorrect choices:

a. Administering oxygen therapy may be indicated in some cases, but it does not directly address the prevention of respiratory complications associated with impaired mobility.

b. Incentive spirometry exercises are useful for promoting lung expansion and preventing atelectasis, but they are not the highest priority intervention for preventing respiratory complications.

d. Prophylactic antibiotics are not routinely administered to all patients with impaired mobility. Their use should be based on specific indications determined by the healthcare provider.

Providing a clutter-free environment with clear pathways reduces the risk of falls and promotes a safe ambulatory environment for patients with impaired mobility.

Incorrect choices:

b. Bed rails are not recommended as a fall prevention measure due to the potential for entrapment and other associated risks. They should only be used when necessary and based on an individualized assessment.

c. Administering sedatives can increase the risk of falls by causing drowsiness and impaired cognition. It is not a suitable fall prevention intervention.

d. Leaving the patient unattended during ambulation increases the risk of falls. Patients with impaired mobility should not be left unattended.

The semi-Fowler's position with the knees slightly flexed promotes lung expansion by allowing the diaphragm to descend fully and reducing the risk of respiratory complications in immobile patients.

Incorrect choices:

a. The supine position with the head of the bed elevated may cause the diaphragm to be restricted, limiting lung expansion and potentially leading to respiratory complications.

b. The prone position is not suitable for immobile patients and may increase the risk of pressure ulcers and respiratory difficulties.

c. The lateral position with the affected side down may compromise lung expansion and increase the risk of respiratory complications in immobile patients.

Encouraging frequent changes in position helps prevent contractures by promoting joint mobility and preventing prolonged pressure on specific areas.

Incorrect choices:

b. Applying heat packs to stiff joints may provide temporary relief but does not address the underlying issue of immobility or prevent contractures.

c. Administering muscle relaxants is not the standard intervention for preventing contractures. The focus should be on promoting mobility and range of motion exercises.

d. Using soft restraints to immobilize the extremities is not an appropriate intervention for preventing contractures. Restraints should only be used when necessary and as a last resort, considering the patient's safety and autonomy.

Performing frequent and thorough skin assessments is essential for identifying early signs of pressure ulcers and implementing appropriate preventive measures in patients with limited mobility.

Incorrect choices:

b. Applying petroleum jelly to vulnerable areas may create a barrier but does not address the underlying issue of pressure and does not substitute for regular skin assessments and preventive measures.

c. Placing the patient on an air mattress can provide pressure redistribution, but it should be used based on individualized assessment and healthcare provider recommendations. Skin assessments remain essential.

d. Encouraging the patient to sit for prolonged periods increases the risk of pressure ulcers. Adequate repositioning and regular mobilization should be prioritized to prevent skin breakdown.

Offering fluids at room temperature can enhance the patient's comfort and promote adequate hydration in immobile patients.

Incorrect choices:

b. Limiting fluid intake to prevent incontinence is not appropriate as it can lead to dehydration. Adequate hydration should be maintained, and measures to manage incontinence should be implemented separately.

c. Providing a straw for easier drinking can facilitate fluid intake, but it may not be suitable for all patients or situations. Individualized assessment and patient preference should be considered.

d. Continuous intravenous fluids may not be necessary for all immobile patients and should be based on specific indications determined by the healthcare provider. Oral intake should be encouraged unless contraindicated.

Encouraging frequent ambulation and leg exercises helps prevent venous stasis and promotes blood flow, reducing the risk of venous thromboembolism (VTE) in immobile patients.

Incorrect choices:

b. Administering sedatives can increase the risk of VTE by promoting immobility and reducing leg movement. It is not an appropriate preventive measure.

c. Applying cold compresses to the lower extremities does not directly prevent VTE. Warm compresses may be used to promote circulation, but prevention strategies primarily focus on mobilization and blood flow promotion.

d. Limiting fluid intake does not directly prevent VTE. Adequate hydration should be maintained to promote circulation and prevent complications such as dehydration and urinary tract infections.