A nurse is teaching a client who has a history of deep vein thrombosis about prevention of pulmonary embolism.
Which of the following statements by the client indicates understanding of the teaching?
“I should avoid smoking cigarettes.”
“I should take aspirin every day.”
“I should limit my fluid intake.”
“I should wear tight-fitting socks.”.
The Correct Answer is A
The correct answer is choice A. “I should avoid smoking cigarettes.” Smoking cigarettes increases the risk of blood clots and deep vein thrombosis (DVT), which can lead to pulmonary embolism (PE) if the clot travels to the lungs. Smoking also damages the blood vessels and reduces oxygen levels in the blood.
Choice B is wrong because aspirin is not a recommended medication for preventing PE. Aspirin is a type of antiplatelet drug that prevents platelets from sticking together and forming clots, but it does not affect the clotting factors in the blood that are involved in DVT and PE. Anticoagulants, also known as blood thinners, are the preferred medications for preventing and treating DVT and PE, as they prevent further clot formation and decrease the chances of new clots.
Choice C is wrong because limiting fluid intake can increase the risk of dehydration, which can thicken the blood and make it more prone to clotting. Drinking plenty of water is important for preventing DVT and PE, especially when traveling or being immobile for long periods of time.
Choice D is wrong because wearing tight-fitting socks can restrict blood flow in the legs and increase the risk of DVT and PE.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hematuria.
Hematuria is the presence of blood in the urine and it indicates a bleeding complication from alteplase therapy.Alteplase is a thrombolytic drug that dissolves blood clots and restores blood flow, but it can also cause significant bleeding.
Hematuria requires immediate intervention by the nurse to stop the infusion and treat the bleeding.
Choice A is wrong because a blood pressure of 150/90 mmHg is not a contraindication for alteplase therapy.Alteplase should not be given to patients with severe uncontrolled hypertension, defined as systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg.
Choice B is wrong because a heart rate of 100/min is not a sign of adverse reaction to alteplase therapy.Alteplase can cause cardiac arrhythmias, but they are usually transient and do not require treatment.
Choice C is wrong because a hemoglobin of 12 g/dL is within the normal range for adults (13.5-17.5 g/dL for males and 12-15.5 g/dL for females).
A low hemoglobin level may indicate bleeding or hemolysis from alteplase therapy and should be monitored closely.
Correct Answer is A
Explanation
The correct answer is choice A. Administer oxygen therapy.The priority action by the nurse for a client who has a pulmonary embolism is to increase perfusion and oxygenation by providing oxygen therapy.
This can help reduce hypoxemia, dyspnea, and chest pain.
Oxygen therapy can also prevent further clotting and pulmonary vasoconstriction.
Choice B is wrong because obtaining a chest x-ray is not the immediate action for a client with a pulmonary embolism.A chest x-ray can help confirm the diagnosis, but it is not a priority over oxygen therapy.
Choice C is wrong because starting an IV line is not the first action for a client with a pulmonary embolism.An IV line can facilitate the administration of fluids and medications, such as anticoagulants and thrombolytics, but it is not as urgent as oxygen therapy.
Choice D is wrong because giving morphine for pain is not the most important action for a client with a pulmonary embolism.Morphine can help relieve pain and anxiety, but it can also depress respiration and lower blood pressure, which can worsen the condition of the client.
Normal ranges for oxygen saturation are 95% to 100%.
Normal ranges for blood pressure are 120/80 mmHg or lower.
Normal ranges for heart rate are 60 to 100 beats per minute.Normal ranges for respiratory rate are 12 to 20 breaths per minute.
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