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.)
(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

Answer and Explanation

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 B

Explanation

A. Distribution of protein: While protein distribution may be affected in kidney disease, it is not a primary function of the kidneys.

B. Filtration of the blood: The kidneys are responsible for filtering waste products and excess substances from the blood. In kidney failure, this filtration process is impaired, leading to the accumulation of toxins in the body.

C. Metabolism of medications: Although the kidneys do play a role in drug excretion, drug metabolism primarily occurs in the liver. Kidney failure may affect the excretion phase.

D. Ability to hold urine: While kidney failure can affect urinary function, the ability to hold urine is primarily a bladder function, not directly a function of the kidneys.

A. Narrowed pulse pressure B. Bradycardia C. Night sweats D. Confusion

Correct Answer is D

Explanation

A. Narrowed pulse pressure: A narrowed pulse pressure can indicate various cardiovascular issues but is not a specific sign of pneumonia.

B. Bradycardia: Bradycardia may occur due to various reasons, including medications or underlying health conditions, but it is not a common sign of pneumonia.

C. Night sweats: While night sweats can occur with pneumonia, they are more associated with infections such as tuberculosis or certain malignancies. It's not a classic presentation.

D. Confusion: Confusion is a common manifestation of pneumonia in older adults due to hypoxia, dehydration, or fever. Older adults often present atypically with changes in mental status during infections.

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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.) (Select All that Apply.)

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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.)
(Select All that Apply.)