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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B"}}
Explanation
The correct answers are:
- Immunoglobulin administration: Passive – Artificial Immunity
- Antibodies produced by body after exposure to live pathogen: Active – Natural Immunity
- Vaccine administration: Active – Artificial Immunity
- Antibodies passed from mother to fetus: Passive – Natural Immunity
- Antibodies produced by body after exposure to attenuated virus: Active – Artificial Immunity
A. Immunoglobulin administration involves injecting pre-formed antibodies from an external source, such as human or animal serum, to provide immediate but temporary protection. This does not stimulate the recipient’s immune system to produce antibodies or memory cells, aligning with passive – artificial immunity.
B. Exposure to a live pathogen triggers the body’s immune system to produce antibodies and memory cells, conferring long-term protection. This natural process of immune activation matches active – natural immunity, as the body actively responds to the pathogen without artificial intervention.
C. Vaccine administration introduces attenuated or inactivated pathogens, prompting the immune system to produce antibodies and memory cells without causing disease. This artificial induction of immunity aligns with active – artificial immunity, as it mimics natural infection but is deliberately administered.
D. Antibodies passed from mother to fetus, primarily immunoglobulin G (IgG) through the placenta, provide temporary protection to the newborn without active immune response. This natural transfer of antibodies corresponds to passive – natural immunity, as it occurs without medical intervention.
E. Exposure to an attenuated virus via vaccination stimulates the immune system to produce antibodies and memory cells, offering long-term protection. This controlled, artificial exposure aligns with active – artificial immunity, as it involves deliberate administration of a weakened pathogen to induce an immune response.
Correct Answer is B
Explanation
Choice A reason: Blood pressure of 84/50 mm Hg indicates decompensated shock, not the compensatory stage. In the compensatory stage, the body maintains blood pressure through vasoconstriction and tachycardia. Hypotension suggests failure of compensatory mechanisms, leading to inadequate tissue perfusion and progression to a more severe stage of shock, requiring immediate intervention.
Choice B reason: Confusion is a hallmark of the compensatory stage of shock. Reduced cerebral perfusion due to decreased blood volume or cardiac output impairs brain function, causing altered mental status. The sympathetic nervous system is activated, redirecting blood to vital organs, but subtle neurological changes like confusion occur as early signs of inadequate oxygen delivery to the brain.
Choice C reason: Anuria, or absence of urine output, is characteristic of the progressive or decompensated stage of shock. In the compensatory stage, urine output is reduced (oliguria) as the kidneys conserve fluid via the renin-angiotensin-aldosterone system. Anuria indicates severe renal hypoperfusion, which occurs later when compensatory mechanisms fail to maintain adequate circulation.
Choice D reason: Petechiae, small hemorrhagic spots on the skin, are not typical in the compensatory stage of shock. They may occur in disseminated intravascular coagulation (DIC), a complication of severe shock, but not in early compensatory stages. The body prioritizes vasoconstriction and fluid conservation, with no direct link to petechial formation in this phase.
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