During rounds, which patient observation would require the charge nurse to intervene due to immobility-related risk?

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Multiple Choice

During rounds, which patient observation would require the charge nurse to intervene due to immobility-related risk?

Immobility increases the risk of pressure injuries and venous stasis, which can lead to a pressure ulcer or a DVT. When a patient remains seated in a chair for several hours, constant pressure on the seating areas reduces blood flow to the skin and underlying tissues and can cause breakdown quickly. The observation of someone sitting in a chair for 2 1/2 hours signals a high risk that needs an intervention to relieve pressure and promote circulation. The appropriate response is to reposition the patient, assess the skin for early signs of pressure damage, and consider measures to reduce prolonged pressure (such as changing position, using a pressure-relieving cushion, encouraging leg movements or ambulation if possible, and ensuring adequate hydration). The other scenarios reflect either ongoing movement or standard immobilization precautions rather than an acute immobility-related risk needing urgent intervention: turning to the side is a recent repositioning; a hip replacement with an abduction pillow is postoperative immobilization with its own precautions; and traction keeps a limb immobilized under controlled conditions with monitoring rather than an immediate risk from immobility alone.

Immobility increases the risk of pressure injuries and venous stasis, which can lead to a pressure ulcer or a DVT. When a patient remains seated in a chair for several hours, constant pressure on the seating areas reduces blood flow to the skin and underlying tissues and can cause breakdown quickly. The observation of someone sitting in a chair for 2 1/2 hours signals a high risk that needs an intervention to relieve pressure and promote circulation. The appropriate response is to reposition the patient, assess the skin for early signs of pressure damage, and consider measures to reduce prolonged pressure (such as changing position, using a pressure-relieving cushion, encouraging leg movements or ambulation if possible, and ensuring adequate hydration).

The other scenarios reflect either ongoing movement or standard immobilization precautions rather than an acute immobility-related risk needing urgent intervention: turning to the side is a recent repositioning; a hip replacement with an abduction pillow is postoperative immobilization with its own precautions; and traction keeps a limb immobilized under controlled conditions with monitoring rather than an immediate risk from immobility alone.

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