The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system?
a. Inspect chest wall movements primarily during the expiratory cycle.
b. Auscultate the entire lung region to assess lung sounds.
c. Focus auscultation on the upper lung fields.
d. Assess the patient at least every 4 hours.
ANS: B
Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.
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