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 ["100"]

Explanation

Volume to be infused: 50 mL

Time: 30 minutes = 0.5 hours

Formula:

mL/hr =Total volume (ml)Time (hr)

= 50ml0.5hr

=100ml/hr

A. Bradycardia. B. Hypertension C. Bleeding D. Sedation

Correct Answer is D

Explanation

A. Bradycardia: Bradycardia is not a common side effect of diphenhydramine. This medication primarily causes sedation and anticholinergic effects.

B. Hypertension: Hypertension is not commonly associated with diphenhydramine, which tends to have more sedative and anticholinergic side effects.

C. Bleeding: Bleeding is not a known side effect of diphenhydramine. It does not affect clotting mechanisms or platelet function.

D. Sedation: Sedation is a common side effect of diphenhydramine, which is an antihistamine with sedative properties. Clients should be advised about possible drowsiness and to avoid activities that require alertness, like driving, while taking it.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is a side effect of this medication?

Correct Answer is D

Explanation

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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.)