A nurse is caring for an immobile patient. What is the most appropriate nursing intervention to implement?

Question

a. Turn the patient every 4 hours.
b. Apply an abdominal binder while the patient is lying in bed.
c. Encourage the regular use of incentive spirometry while awake.
d. Maintain the patient's maximum fluid intake of 1000 mL daily.

Answer 1

C
You can also promote lung expansion through regular deep breathing exercises, use of an incentive spirometer, and forceful coughing. Changing the position of the patient at least every 2 hours, not 4, allows the dependent lung regions to re-expand, maintains the elastic recoil property of the lungs, and clears the dependent lung regions of pulmonary secretions. Your assessment will determine if patients need more frequent position changes. An application of an abdominal binder will restrict chest expansion. Make sure that the immobile patient has a fluid intake of at least 2000 mL per day, if not contraindicated, to help keep mucociliary clearance intact.