🔷 Administer an antipyretic

🔷 A temperature of 39°C (102.2°F) indicates fever, and antipyretic medications such as acetaminophen or ibuprofen help lower body temperature.

🔷 Antipyretics work by affecting the hypothalamus, which regulates body temperature.

🔷 Reducing fever can decrease discomfort, metabolic demand, dehydration risk, and oxygen consumption.

🔷 The nurse should monitor temperature trends, response to medication, and signs of infection while administering the antipyretic safely.

💎 Encourage the client to rest

💎 Fever increases the body’s metabolic rate and oxygen demand, which can lead to fatigue and weakness.

💎 Rest helps conserve energy so the body can focus on fighting the underlying illness or infection.

💎 Activity during fever may worsen exhaustion, increase dehydration, and elevate oxygen consumption further.

💎 The nurse should promote comfort measures, decrease unnecessary activity, and monitor for worsening symptoms.

🌿 Give the client a cold beverage

🌿 Fever increases fluid loss through sweating and increased metabolism, placing the client at risk for dehydration.

🌿 Providing cool or cold fluids helps lower body temperature slightly while maintaining hydration.

🌿 Adequate hydration supports circulation, temperature regulation, and overall recovery.

🌿 The nurse should encourage oral fluids if the client can safely swallow and monitor intake and output.

❌ Put a warm blanket on the client

❌ Warm blankets can increase body temperature further and may worsen the fever.

❌ Lightweight bedding and a comfortable room temperature are more appropriate unless the client is actively shivering during fever onset.

🔷 A gait belt is a safety device used to help support and stabilize a client during ambulation or transfers.

🔷 It allows the nurse to maintain a secure grip and quickly assist the client if weakness, dizziness, loss of balance, or instability occurs.

🔷 Using a gait belt significantly reduces the risk of falls and injuries for both the client and the nurse.

🔷 The belt should be applied snugly around the client’s waist over clothing, and the nurse should walk slightly behind and to the side of the weaker side if one exists.

🔷 Nurses should also assess the client’s strength, balance, level of consciousness, orthostatic blood pressure, and use of assistive devices before ambulation.

🔷 Proper footwear, uncluttered pathways, and adequate lighting are additional fall-prevention measures.

❌ Allow the client to lean on the nurse for support

❌ Allowing the client to lean heavily on the nurse is unsafe and may cause both the client and nurse to fall.

❌ The nurse should provide controlled support using proper transfer and ambulation equipment such as a gait belt.

❌ Stand in front of the client as they are ambulating

❌ Standing directly in front can obstruct movement and increase fall risk.

❌ The nurse should stand slightly to the side and behind the client for better support and balance control.

❌ A mechanical lift

❌ Mechanical lifts are used for clients who cannot bear weight or require full transfer assistance.

❌ The question asks about assisting with ambulation, where a gait belt is the most appropriate intervention.

🔷 Pressure ulcer

🔷 Pressure ulcers are one of the most common complications of prolonged immobility.

🔷 When a client remains in one position for extended periods, continuous pressure decreases blood flow to the skin and underlying tissues, especially over bony prominences such as the sacrum, heels, hips, elbows, and shoulders.

🔷 Reduced circulation leads to tissue ischemia, skin breakdown, and ulcer formation.

🔷 Clients who are immobile are at especially high risk because they may be unable to reposition themselves independently.

🔷 Nursing interventions include frequent repositioning, pressure-relieving surfaces, skin assessments, adequate nutrition, hydration, and keeping the skin clean and dry.

💎 Constipation

💎 Prolonged immobility slows gastrointestinal motility and decreases peristalsis, increasing the risk for constipation.

💎 Reduced activity weakens the natural movement of stool through the intestines, causing hard stools, abdominal discomfort, bloating, and difficulty passing stool.

💎 Immobile clients may also have decreased fluid intake, reduced appetite, pain medication use, or weakened abdominal muscles, which further worsen constipation.

💎 Nursing interventions include encouraging fluids, fiber intake, mobility as tolerated, bowel routines, and stool softeners if prescribed.

❌ Sepsis

❌ Sepsis is a severe systemic infection and is not a direct common complication of immobility itself.

❌ However, immobility-related complications such as pressure ulcers or pneumonia can eventually lead to infection if untreated.

❌ Anemia

❌ Anemia is not considered a common direct complication of immobility.

❌ It is more commonly related to blood loss, nutritional deficiency, chronic disease, or bone marrow problems.

❌ Dehydration

❌ Dehydration may occur in immobile clients if fluid intake is poor, but it is not one of the classic primary complications of immobility.

❌ The most recognized complications include pressure ulcers, constipation, muscle atrophy, atelectasis, and venous thromboembolism.

🔷 Crutches must be properly fitted to the client’s height and body measurements to ensure safe ambulation and prevent injury.

🔷 Incorrectly fitted crutches can cause complications such as falls, nerve damage, poor balance, shoulder strain, and pressure injury to the axilla.

🔷 The nurse should ensure there is appropriate spacing between the axilla and the crutch pad, usually about 2–3 finger widths, and that the elbows remain slightly flexed when using the handgrips.

🔷 Providing properly fitted crutches also allows the nurse to teach the client correct crutch-walking techniques, weight-bearing precautions, and stair safety.

🔷 Safety and injury prevention are the priority, especially with a lower-extremity fracture.

🔷 The nurse should encourage the client to use equipment specifically adjusted for their body rather than borrowed devices that may not fit correctly.

❌ “Are the crutches in good condition?”

❌ Even if the crutches are in good condition, they may not fit the client properly.

❌ Proper sizing and fitting are more important than appearance or condition alone.

❌ “Please remind your neighbor to teach you how to walk with crutches when they give them to you.”

❌ Crutch teaching should be performed by trained healthcare professionals, not neighbors.

❌ Incorrect instruction may increase the client’s risk for falls or improper use.

❌ “That is a great idea to save money.”

❌ This response ignores the importance of safe fitting and proper teaching.

❌ Client safety should take priority over convenience or cost savings.

🔷 Extension

🔷 Extension is a passive range-of-motion (ROM) movement that straightens the joint and increases the angle between body parts.

🔷 For the knee, extension occurs when the lower leg is straightened fully.

🔷 Performing extension exercises helps maintain joint mobility, muscle length, circulation, and functional movement while preventing stiffness and contracture formation.

🔷 Contractures develop when joints remain immobile for long periods, causing shortening of muscles and connective tissue.

🔷 Regular extension exercises help preserve the knee’s ability to straighten normally for walking, standing, and transferring.

💎 Flexion

💎 Flexion decreases the angle of the joint by bending it.

💎 Knee flexion occurs when the lower leg bends backward toward the thigh.

💎 Flexion exercises help maintain joint mobility, prevent muscle shortening, and preserve normal knee function.

💎 Alternating flexion and extension keeps the joint moving through its normal range and decreases the risk of permanent stiffness or deformity.

💎 Passive ROM is especially important for clients who are weak, paralyzed, unconscious, or unable to move independently.

❌ Adduction

❌ Adduction refers to moving a limb toward the midline of the body.

❌ This movement mainly applies to joints such as the shoulder or hip, not the knee joint.

❌ Abduction

❌ Abduction means moving a limb away from the midline.

❌ The knee primarily performs flexion and extension rather than abduction or adduction.

🔷 An SpO₂ of 89% is below the expected normal oxygen saturation range and may indicate hypoxemia.

🔷 The nurse’s priority is to immediately assess the client for signs of respiratory distress, such as dyspnea, tachypnea, cyanosis, restlessness, use of accessory muscles, abnormal breath sounds, or altered mental status.

🔷 Nursing care follows the nursing process, so assessment must occur before implementing or reporting interventions unless the client is in immediate collapse.

🔷 The nurse should determine how severe the oxygenation problem is and whether urgent interventions such as oxygen administration or rapid response activation are needed.

🔷 Assessment findings help guide the next action and provide important information if the provider must be notified.

🔷 Early recognition of respiratory compromise can prevent respiratory failure and deterioration.

❌ Call the provider

❌ The provider may need to be notified, but the nurse should first assess the client’s respiratory status.

❌ Assessment data is necessary before reporting the condition.

❌ Finish collecting vital signs

❌ The low oxygen saturation is a priority abnormal finding requiring immediate assessment.

❌ Delaying assessment to complete routine tasks may place the client at risk.

❌ Document the finding

❌ Documentation is important, but immediate assessment and intervention take priority.

❌ The nurse must first evaluate the client’s condition and safety.

💎 Clients with prolonged immobility are at increased risk for urinary stasis, which occurs when urine remains in the bladder instead of being emptied completely.

💎 Stagnant urine creates an environment where bacteria can grow and multiply, increasing the risk for a urinary tract infection (UTI).

💎 Immobility can reduce bladder emptying efficiency because of weakened muscles, reduced mobility to the bathroom, and incomplete voiding.

💎 In addition, clients who remain in bed for long periods may have decreased fluid intake, which can further concentrate urine and promote bacterial growth.

💎 Nursing interventions include encouraging fluids if not contraindicated, promoting mobility as tolerated, assisting with regular toileting, and monitoring for urinary retention or infection symptoms.

❌ “A urinary catheter could resolve this problem for you.”

❌ Urinary catheters actually increase the risk for UTIs because they provide a pathway for bacteria to enter the urinary tract.

❌ Catheters should only be used when medically necessary.

❌ “Sometimes people with immobility do not perform perineal care properly.”

❌ Poor hygiene can contribute to infection risk, but the primary immobility-related cause is urinary stasis.

❌ The question focuses on why immobility itself increases UTI risk.

❌ “Because you are not drinking enough fluids.”

❌ Decreased fluid intake can contribute to UTIs, but it is not the main explanation related to immobility.

❌ Urinary retention and stagnant urine are the primary reasons.

🔷 A blood pressure of 190/110 mmHg is severely elevated, but before taking further action, the nurse should first verify the accuracy of the reading.

🔷 An incorrect cuff size, improper positioning, movement, talking, or equipment error can produce falsely high blood pressure measurements.

🔷 Using a cuff that is too small commonly causes falsely elevated readings.

🔷 The nurse should ensure the client is seated properly, the arm is supported at heart level, the cuff fits correctly, and the client has rested before repeating the measurement.

🔷 Reassessment is part of the nursing process and helps confirm whether the reading is truly abnormal before notifying the provider or initiating additional interventions.

🔷 If the repeated blood pressure remains critically high, the nurse should then assess for symptoms such as headache, chest pain, blurred vision, neurologic changes, or shortness of breath and notify the provider promptly.

❌ Call the health care provider

❌ The provider may need to be notified if the pressure remains elevated.

❌ However, the nurse should first verify the accuracy of the reading.

❌Educate the client about hypertension

❌ Client education is important but not the immediate priority with a potentially inaccurate severe reading.

❌ The nurse must first confirm the blood pressure result.

❌ Document the finding

❌ Documentation should occur after reassessment and confirmation.

❌ Immediate reassessment takes priority over charting.

🔷 An irregular radial pulse may indicate a cardiac dysrhythmia or pulse deficit, so the nurse should further assess the heart rhythm by auscultating the apical pulse.

🔷 The apical pulse provides a more accurate assessment of heart rate and rhythm because it is measured directly at the heart.

🔷 When a pulse is irregular, it should always be counted for a full 60 seconds to accurately identify skipped beats, rhythm irregularities, or rate abnormalities.

🔷 Comparing the apical and radial pulses can also help identify a pulse deficit, which occurs when not all heartbeats are strong enough to be felt at the radial artery.

🔷 After completing the assessment, the nurse can determine whether further interventions such as provider notification or cardiac monitoring are needed.

❌ Document the finding

❌ Documentation is important, but the nurse should first perform additional assessment to gather more accurate data.

❌ An irregular pulse requires further evaluation before charting alone.

❌ Assess the pedal pulse

❌ Pedal pulse assessment evaluates circulation to the lower extremities.

❌ It does not further assess the irregular heart rhythm detected at the radial pulse.

❌ Recommend an order for an EKG

❌ An EKG may eventually be needed if dysrhythmia is suspected.

❌ However, the nurse should first complete the appropriate cardiac assessment.

💎 If the nurse cannot palpate a pedal pulse but the client has brisk capillary refill, circulation may still be present.

💎 A Doppler ultrasound device helps detect blood flow that may be too weak to feel manually.

💎 This is the appropriate next step before concluding that the pulse is absent or circulation is impaired.

💎 Brisk capillary refill suggests adequate peripheral perfusion, so the nurse should further assess rather than assume vascular compromise.

💎 Doppler assessment is especially useful in clients with edema, peripheral vascular disease, obesity, hypotension, or weak pulses.

❌ Document the finding as absent pulse

❌ The nurse should not document the pulse as absent until further assessment with a Doppler is attempted.

❌ Additional assessment is necessary because circulation signs are still present.

❌ Palpate the radial pulse

❌ The radial pulse assesses circulation in the upper extremities, not the affected foot.

❌ It does not evaluate the missing pedal pulse directly.

❌ Palpate the popliteal pulse instead

❌ The popliteal pulse may provide additional vascular information, but the best immediate next action is Doppler assessment of the pedal pulse itself.

❌ The nurse should attempt to verify distal blood flow directly.