The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.
immobility
smoking
history of stomach ulcers
overhydration
taking birth control pills
Correct Answer : A,B,E
A. Immobility is a significant risk factor for venous thromboembolism (VTE) since prolonged inactivity can lead to stasis of blood flow, increasing clot formation risk.
B. Smoking contributes to hypercoagulability and vascular damage, both of which elevate the risk of clot formation in veins.
C. A history of stomach ulcers is not directly associated with an increased risk of blood clots; rather, it pertains more to gastrointestinal health.
D. Overhydration generally does not increase the risk of blood clots; rather, maintaining adequate hydration is important for circulation.
E. Taking birth control pills can increase the risk of blood clots due to hormonal changes that promote hypercoagulability.
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Correct Answer is A
Explanation
A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.
Correct Answer is E
Explanation
A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.