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 D

Explanation

A. "I will rinse my mouth after each dose to prevent thrush." Ipratropium bromide is an anticholinergic bronchodilator, and it does not typically increase the risk of oral thrush. Rinsing the mouth after use is more commonly recommended with corticosteroid inhalers.

B. "I will use this medication early in the morning so I am not urinating all night." Ipratropium bromide does not significantly affect urination or the frequency of urination, as it primarily targets the respiratory system.

C. "I will make sure to use this in combination with a corticosteroid inhaler." Although it may be used in combination with corticosteroids, this is not specific to Ipratropium's side effects. This answer does not directly address side effect management.

D. "I will suck on hard candies to cope with dry mouth." A common side effect of Ipratropium bromide is dry mouth due to its anticholinergic properties. Sucking on hard candies is an appropriate way to manage this side effect.

A. Danazol B. Finasteride C. Fluoxymesterone D. Methyltestosterone

Correct Answer is B

Explanation

A. Danazol: Danazol is primarily used for conditions like endometriosis and is not indicated for BPH treatment.

B. Finasteride: Finasteride is a 5-alpha-reductase inhibitor that reduces the size of the prostate and is commonly prescribed for managing symptoms of BPH.

C. Fluoxymesterone: Fluoxymesterone is an anabolic steroid and is not used for treating BPH.

D. Methyltestosterone: Methyltestosterone is also an anabolic steroid and does not address the symptoms of BPH.

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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.)

Nursing Test Bank

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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.)