NCLEX-RN

Answer: B - In order to avoid infection, a common complication of immobility, the nurse’s plan of care should focus on frequent turning and suctioning of oral and tracheal secretions. Unconscious clients lack the ability to expectorate secretions; therefore there is an increased risk of secretions pooling in the lungs. Pooling of secretions can lead to pneumonia or other respiratory infection. Option A is incorrect; the indwelling catheter is changed every two to four weeks or as necessary (e.g., crystallization or obstruction). Frequently changing the catheter can injure the urethral lining or bladder mucosa, which may lead to further infection. Intermittent catheterization is more suitable for conscious clients. Option C is incorrect; clean and uncontaminated water and feeding syringe may be used during feeding. Avoid suctioning for longer than 15 seconds.