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 ["4"]

Explanation

Formula: (Desired Dose / Dose on Hand) × Volume
(40 mg / 10 mg) × 1 mL = 4 mL
Answer: 4 mL

A. Daily or weekly weight B. Sodium level C. Tissue turgor D. Intake and output

Correct Answer is A

Explanation

A. Daily or weekly weight: Daily or weekly weight measurements are a reliable way to assess fluid retention. A sudden increase in weight can indicate fluid overload.

B. Sodium level: While sodium levels can provide some information about fluid balance, they are not as direct or reliable as weight measurements for assessing fluid retention.

C. Tissue turgor: Tissue turgor can give some insight into hydration status but is subjective and less reliable compared to weight measurements, especially in clients with chronic conditions.

D. Intake and output: While monitoring intake and output is important for assessing fluid balance, it may not accurately reflect fluid retention, as it doesn't account for fluid shifts or loss through other routes.

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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.)

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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.)