A nurse is caring for five patients.
For which patients should the nurse assess a high risk for developing a pulmonary embolism (PE)? Select all three that apply.

Patient with new spinal cord injury on a rotating bed.

Young obese patient with a fractured femur.

Patient who had a reaction to contrast dye yesterday.

Older patient who is one day post hip replacement surgery.

Answer and Explanation

Correct Answer : B,D

Choice A rationale

A patient with a new spinal cord injury on a rotating bed is not at a high risk for developing a pulmonary embolism. The rotating bed is specifically designed to prevent complications associated with immobility, such as venous stasis and pressure ulcers. The constant movement of the bed helps to maintain blood flow and prevent the pooling of blood in the extremities, thereby reducing the risk of deep vein thrombosis and subsequent pulmonary embolism.

Choice B rationale

A young obese patient with a fractured femur is at a high risk for developing a pulmonary embolism. Obesity is a hypercoagulable state, increasing the baseline risk of thrombus formation. A fractured femur, especially if it requires immobilization, causes significant venous stasis and potential endothelial injury. This combination of factors, adhering to Virchow's triad, creates a highly prothrombotic environment, making the development of DVT and PE very likely.

Choice C rationale

A patient who had a reaction to contrast dye yesterday is not at a high risk for developing a pulmonary embolism. Allergic reactions to contrast dye are typically associated with hypersensitivity responses, affecting systems such as the respiratory, cardiovascular, and integumentary. There is no known physiological mechanism or evidence to suggest that a contrast dye reaction, even a severe one, directly increases the risk of developing a pulmonary embolism in the subsequent days.

Choice D rationale

An older patient who is one day post hip replacement surgery is at a very high risk for developing a pulmonary embolism. Surgical procedures, particularly orthopedic surgeries like hip replacements, cause significant endothelial injury and a hypercoagulable state. The post-operative period often involves extended immobility, leading to venous stasis. These three components of Virchow's triad converge to create an ideal environment for the formation of a deep vein thrombosis, which can easily embolize to the lungs.

Choice E rationale

A young man with an exacerbation of asthma is not at a high risk for developing a pulmonary embolism. Asthma is a chronic inflammatory disease of the airways characterized by bronchoconstriction. While a severe asthma exacerbation can lead to hypoxemia and respiratory distress, it does not directly cause the hypercoagulable state, venous stasis, or endothelial injury necessary to form a deep vein thrombosis. Therefore, it is not a direct risk factor for a pulmonary embolism

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Burn injuries, especially those affecting the face, neck, and chest, significantly increase the risk of smoke inhalation and airway edema. Administering oxygen is crucial to counteract potential hypoxia resulting from impaired gas exchange in the lungs, carbon monoxide poisoning, and cellular anoxia. The goal is to maintain adequate tissue oxygenation and prevent respiratory failure, which is a leading cause of mortality in burn victims.

Choice B rationale

Fluid restriction is contraindicated in burn patients because they experience massive fluid shifts from the intravascular space into the interstitial spaces due to increased capillary permeability caused by the inflammatory response. This leads to hypovolemia and burn shock. Aggressive fluid resuscitation is necessary to maintain adequate circulating blood volume, tissue perfusion, and kidney function, preventing multi-organ system failure.

Choice C rationale

Assessing for airway patency is the absolute priority in a patient with burns to the face, neck, and chest. The heat and smoke can cause immediate laryngeal edema and subsequent upper airway obstruction, which can be life-threatening. The nurse must continuously monitor for signs such as stridor, hoarseness, and dyspnea, and prepare for potential intubation to secure the airway.

Choice D rationale

Elevating the extremities is a vital intervention for burn patients without fractures. The purpose of elevation is to reduce edema formation by promoting venous return and decreasing hydrostatic pressure in the burned limbs. This helps to maintain circulation, minimize tissue damage, and reduce pain. Edema is a major complication of burns due to the inflammatory response and increased capillary permeability.

Choice E rationale

Placing a cooling blanket on a burn patient is inappropriate and can be harmful. While cooling the burn area itself can decrease the inflammatory response, excessive cooling of the entire body, especially a large surface area, can lead to systemic hypothermia. Hypothermia impairs coagulation, decreases cardiac output, and can increase the risk of infection, all of which are detrimental to a burn patient.

A. "I will avoid hot showers or baths.”. B. "I will isolate myself until it heals so I don't spread it to others.”. C. "I will apply unscented moisturizer daily.”. D. "I will drink adequate amounts of water—about 100 oz daily.”. --- . . .

Correct Answer is B

Explanation

Choice A rationale

Contact dermatitis is an inflammatory reaction of the skin caused by contact with an irritant or allergen. Avoiding hot showers and baths is a correct teaching point, as heat can exacerbate itching and further irritate the skin barrier, leading to increased inflammation and discomfort. This statement shows correct understanding.

Choice B rationale

Contact dermatitis is not contagious. The rash is a localized inflammatory response and cannot be spread from person to person. A statement about isolating oneself indicates a significant misunderstanding of the condition's etiology and transmission. This is the statement that requires further education from the nurse.

Choice C rationale

Applying unscented moisturizer is a correct and helpful intervention for contact dermatitis. Moisturizers help to restore the skin's barrier function, reduce dryness and scaling, and can soothe the irritated area. Using an unscented product is important to avoid further irritation from potential allergens in fragrances.

Choice D rationale

Maintaining adequate hydration is beneficial for overall skin health and can support the skin's healing process. While 100 oz may be a large amount for some, drinking adequate fluids is generally a sound recommendation for promoting skin barrier function and systemic health during an inflammatory process. .

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A nurse is caring for five patients. For which patients should the nurse assess a high risk for developing a pulmonary embolism (PE)? Select all three that apply.

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Naxlex Comprehensive Predictor Exams

A patient is brought to the emergency department with partial thickness burns to their face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this patient?

Correct Answer is ["A","C","D"]

Explanation

A 22-year-old patient has an itchy rash on his left arm that has been diagnosed as contact dermatitis. Which of the following patient statements indicates a need for more education?

Correct Answer is B

Explanation

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A nurse is caring for five patients.
For which patients should the nurse assess a high risk for developing a pulmonary embolism (PE)? Select all three that apply.