NCLEX-PN® ExaminationBasic Care and ComfortEasy
An LPN is caring for a client with a new prescription for bed rest following a spinal injury. Which intervention is most important to prevent complications related to immobility?
- AProviding a high-calorie, high-protein diet to promote tissue healing.
- BRepositioning the client every 2 hours and assessing skin integrity.
- CEncouraging the client to perform deep breathing and coughing exercises every 4 hours.
- DAssisting the client with active range of motion exercises to all extremities daily.
Show answer & explanationAnswer & explanation
Correct answer: B. Repositioning the client every 2 hours and assessing skin integrity.
Repositioning every 2 hours and assessing skin integrity are crucial interventions to prevent pressure injuries, a common and serious complication of immobility, especially in clients with spinal injuries who may have impaired sensation.
Why the other options are wrong
- A. A high-calorie, high-protein diet is important for healing but does not directly prevent pressure injuries or other physical complications of immobility.
- C. Deep breathing and coughing are important for respiratory health but not the most critical for preventing all immobility complications.
- D. Active range of motion is beneficial for joint mobility, but if the client cannot perform it, passive range of motion would be needed. However, preventing pressure injuries is a higher priority to avoid immediate skin breakdown.
Immobility Complication Prevention
Proactive nursing interventions aimed at mitigating adverse effects of prolonged bed rest or limited movement, such as pressure injuries, DVT, and respiratory issues.
- Repositioning prevents pressure injuries.
- Early mobilization (if allowed) is key.
- Respiratory exercises prevent pneumonia.
Memory trick: Regular repositioning protects the skin's integrity, a vital defense against immobility's severity.