A nurse is working on a surgical unit and is caring for a client who returned from the Post Anesthesia Care Unit (PACU) 90 minutes ago. Which interventions will decrease the client’s risk of developing a pulmonary embolism? (Select all that apply)

Encourage client to do active leg exercises

Maintain the head of the bed at 90 degrees

Ambulate the client early

Administer aspirin and warfarin

Apply compression stockings

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Active leg exercises promote venous return by activating the calf muscle pump, preventing blood stasis in the lower extremities. Stasis is a key component of Virchow’s triad, increasing the risk of deep vein thrombosis (DVT), which can lead to pulmonary embolism. Regular movement enhances circulation, reducing clot formation in postoperative patients.

Choice B reason: Maintaining the head of the bed at 90 degrees does not directly reduce pulmonary embolism risk. While it may improve respiratory function, it does not address venous stasis or clot formation in the lower extremities, the primary source of pulmonary emboli. This position may also increase discomfort or orthostatic hypotension in some patients.

Choice C reason: Early ambulation enhances venous blood flow by engaging leg muscles, reducing stasis, a major risk factor for deep vein thrombosis and subsequent pulmonary embolism. Postoperative immobility increases clot formation risk, so mobilizing the client soon after surgery, when safe, significantly lowers the likelihood of thromboembolic events in the pulmonary vasculature.

Choice D reason: Aspirin and warfarin are anticoagulants that reduce clotting risk, but their use must be carefully considered due to bleeding risks in postoperative patients. They are not first-line interventions compared to mechanical methods like leg exercises or compression stockings. Their administration requires specific medical orders and monitoring, making them less immediate for prevention.

Choice E reason: Compression stockings apply graduated pressure to the legs, promoting venous return and preventing blood pooling, which reduces the risk of deep vein thrombosis formation. By counteracting stasis, they help prevent clots that could dislodge and cause a pulmonary embolism, making them an effective, non-invasive intervention for postoperative patients.

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

Explanation

Choice A reason: Frequent bowel movements are not typical in peritonitis. Inflammation of the peritoneal cavity causes ileus, reducing bowel motility and leading to constipation or obstipation. Peristalsis slows due to irritation, and the body diverts energy to combat infection, making diarrhea unlikely unless another condition, like gastroenteritis, is present, which is not indicated here.

Choice B reason: A rigid abdomen is a classic sign of peritonitis due to peritoneal inflammation causing muscle guarding and rigidity. The peritoneal irritation from infection or chemical irritants (e.g., bile, gastric contents) triggers involuntary abdominal wall contraction to protect inflamed tissues, resulting in a board-like abdomen, often with severe pain.

Choice C reason: Decreased urinary output occurs in peritonitis due to systemic inflammation and potential hypovolemia from fluid shifts into the peritoneal cavity (third-spacing). The kidneys receive reduced perfusion, activating the renin-angiotensin-aldosterone system, leading to oliguria. This reflects the body’s attempt to conserve fluid in response to systemic stress and inflammation.

Choice D reason: Inability to pass stools is expected in peritonitis due to paralytic ileus, where intestinal motility ceases from inflammation. Peritoneal irritation disrupts normal peristalsis, causing bowel obstruction symptoms like constipation or obstipation. This results from the body’s inflammatory response inhibiting gastrointestinal function, leading to stool retention.

Choice E reason: Hyperactive bowel sounds are not typical in peritonitis. The condition causes paralytic ileus, reducing or absent bowel sounds due to decreased peristalsis from peritoneal inflammation. Hyperactive sounds may occur in early mechanical obstruction but not in peritonitis, where inflammation halts bowel motility, leading to hypoactive or absent sounds.

A. Impaired gas exchange B. Activity intolerance C. Imbalanced nutrition: less than body requirements D. Impaired oral mucous membranes

Correct Answer is A

Explanation

Choice A reason: Impaired gas exchange is the highest priority in Pneumocystis carinii pneumonia (now Pneumocystis jirovecii pneumonia). This opportunistic infection causes alveolar inflammation, reducing oxygen diffusion across the alveolar-capillary membrane. Hypoxemia results, impairing tissue oxygenation. Prioritizing gas exchange ensures adequate oxygen delivery to vital organs, addressing the life-threatening nature of this respiratory infection.

Choice B reason: Activity intolerance occurs in Pneumocystis pneumonia due to hypoxemia and fatigue from infection. While significant, it is secondary to impaired gas exchange, as oxygen delivery is critical for survival. Addressing hypoxemia through oxygen therapy or ventilation support takes precedence, as it directly impacts the patient’s ability to sustain physical activity.

Choice C reason: Imbalanced nutrition: less than body requirements may occur due to increased metabolic demands or poor appetite in Pneumocystis pneumonia. However, it is not the highest priority, as nutritional deficits are less immediately life-threatening than hypoxemia. Correcting gas exchange ensures oxygenation, which supports metabolic processes before addressing long-term nutritional needs.

Choice D reason: Impaired oral mucous membranes may result from opportunistic infections or treatment side effects in Pneumocystis pneumonia. While uncomfortable, it is not life-threatening compared to impaired gas exchange, which causes hypoxemia and risks organ failure. Addressing respiratory function is critical before managing secondary issues like oral health in this acute infection.

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A nurse is working on a surgical unit and is caring for a client who returned from the Post Anesthesia Care Unit (PACU) 90 minutes ago. Which interventions will decrease the client’s risk of developing a pulmonary embolism? (Select all that apply)

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The nurse is assessing a patient with peritonitis. What findings should they expect? (Select all that apply)

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

Explanation

A client is admitted with the diagnosis of Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Correct Answer is A

Explanation

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