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 B

Explanation

A. Vomiting: While vomiting can occur during anaphylaxis, it is not the most immediately life-threatening symptom.

B. Stridor: Stridor indicates upper airway obstruction, which is a critical and life-threatening sign of anaphylaxis. This finding requires immediate intervention, such as administering epinephrine and ensuring airway patency.

C. Hypertension: Hypertension is not typically associated with anaphylaxis; instead, hypotension is more common due to vascular collapse.

D. Urticaria: Urticaria (hives) can occur in anaphylaxis, but it is not as urgent as stridor, which indicates a compromised airway.

A. "Gradually decrease the dose once tolerance to the effect is reached." B. "Take the medication with men is." C. "Distribute the doses evenly throughout the day.” D. "Take the daily dose at bedtime.”

Correct Answer is D

Explanation

A. "Gradually decrease the dose once tolerance to the effect is reached." Tolerance can develop over time, but this approach is not the most effective or safest way to manage sedation.

B. "Take the medication with meals." Taking diphenhydramine with food may help with gastrointestinal side effects but does not reduce sedation.

C. "Distribute the doses evenly throughout the day." Distributing doses evenly may not effectively reduce sedation, as diphenhydramine has sedative effects regardless of timing.

D. "Take the daily dose at bedtime.” Taking diphenhydramine at bedtime can minimize daytime sedation, as the sedative effects will occur during sleep.

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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.)