Question: To prevent complications of immobility, what would be the most effective activities to implement for a client on the first postoperative day after a colon resection?
1. Turn, cough, and deep-breathe every 30 minutes around the clock
2. Get the client out of bed and ambulate to a bedside chair
3. Provide passive range of motion three times a day
4. Immobility is not a concern on the first postoperative day
Rationale: Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing. Passive range of motion maintains joint mobility but is not as effective as weight bearing to prevent venous stasis and the complications of immobility. Turning and coughing every 30 minutes around the clock is too often-it would disrupt effective rest and sleep. Every 2 hours is the standard. Prevention of complications of immobility begins when the client becomes immobilized.
This week’s NCLEX exam practice question came from:
Zerwekh: Illustrated Study Guide for the NCLEX-RN Exam, 7th Edition, Chapter 3, pg 68, question18
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