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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “If my breathing begins to feel tight, I will use the fluticasone immediately." Fluticasone is a corticosteroid, and it is not a rescue medication. It is used for long-term control and does not provide immediate relief for acute symptoms.
B. "I will be sure to use the albuterol nebulizer before the fluticasone." Albuterol is a bronchodilator and should be used first to open the airways, allowing better absorption of fluticasone when used afterward.
C. "I do not need to rinse my mouth after completing the albuterol and fluticasone." Rinsing the mouth after using fluticasone (a corticosteroid) is important to prevent oral thrush. Albuterol alone does not require rinsing, but fluticasone does.
D. "I will use both medications immediately after exercising." Albuterol is often used as a pre-exercise medication for asthma, but fluticasone should be used as directed for maintenance, not as an immediate post-exercise medication.
Correct Answer is ["5.6"]
Explanation
- Convert weight:
- 33 lb ÷ 2.2 = 15 kg
- Calculate total daily dose:
- 30 mg/kg/day × 15 kg = 450 mg/day
- Divide the dose for every 12 hours:
- 450 mg/day ÷ 2 = 225 mg every 12 hours
- Determine volume to administer:
- If 200 mg is in 5 mL, then:
- 225mg200mg ×5ml
- =5.625mL
- Rounded to the nearest tenth: 5.6 mL
Answer: 5.6 mL
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