A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)
Perform passive range of motion exercises.
Place pillows under the client's knees when in bed.
Assess legs for redness.
Apply elastic compression stockings
Massage the calves every shift
Correct Answer : A,C,D
A. Perform passive range of motion exercises. Passive range of motion exercises help maintain circulation and reduce venous stasis, which is crucial for preventing pulmonary embolism in clients who are immobile.
B. Place pillows under the client's knees when in bed. Placing pillows under the knees can actually promote venous stasis and increase the risk of a pulmonary embolism. It is better to keep the legs flat to encourage circulation.
C. Assess legs for redness. Regular assessment of the legs for redness, swelling, or warmth helps in the early detection of deep vein thrombosis (DVT), which can lead to pulmonary embolism if not addressed.
D. Apply elastic compression stockings. Elastic compression stockings promote venous return from the legs to the heart and help prevent DVT, thereby reducing the risk of pulmonary embolism.
E. Massage the calves every shift. Massaging the calves can dislodge a thrombus and potentially lead to a pulmonary embolism. Instead, interventions should focus on preventing thrombus formation.
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Correct Answer is C
Explanation
A. Hypertension: While systemic corticosteroids can lead to hypertension, fluticasone, when inhaled, typically has minimal systemic effects.
B. Polyuria: Polyuria is more associated with systemic corticosteroids or diabetes management, not with inhaled fluticasone.
C. Oral candidiasis: Inhaled corticosteroids like fluticasone can lead to oral thrush, so rinsing the mouth after use is advised to prevent this.
D. Hypoglycemia: Corticosteroids typically cause hyperglycemia rather than hypoglycemia.
Correct Answer is D
Explanation
A. Digoxin: Digoxin requires caution with elevated potassium levels, as hyperkalemia can increase the risk of digoxin toxicity. A potassium level of 5.3 mEq/L is borderline high, so it should be used cautiously.
B. Lisinopril: Lisinopril, an ACE inhibitor, can also increase potassium levels. It may not be the best choice for this client due to the elevated potassium.
C. Potassium iodide: Potassium iodide would further increase the client's potassium level and is contraindicated.
D. Furosemide: Furosemide is a loop diuretic that can help to lower serum potassium levels by promoting potassium excretion. Therefore, it is appropriate for this client with an elevated potassium level.