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. Urine-specific gravity: While urine-specific gravity can provide information on kidney function, it does not specifically measure renal impairment or disease progression, especially in SLE.
B. Serum potassium: Serum potassium levels can be affected by renal function but are not a direct indicator of renal health and can be influenced by many other factors.
C. Serum creatinine: Serum creatinine is a more reliable indicator of renal function, as it reflects how well the kidneys are filtering waste. In clients with SLE, kidney involvement is a common complication.
D. Serum sodium: Serum sodium levels do not directly indicate renal function, though kidney impairment can impact electrolyte levels.
Correct Answer is C
Explanation
A. Vitamin K: Vitamin K is used for anticoagulant reversal, not for acetaminophen toxicity.
B. Flumazenil: Flumazenil is a benzodiazepine antagonist and is not indicated for acetaminophen overdose.
C. Acetylcysteine: Acetylcysteine is the antidote for acetaminophen toxicity, helping to replenish glutathione stores and prevent liver damage.
D. Atropine: Atropine is used for bradycardia or certain poisoning but is not relevant for acetaminophen toxicity.