Practice Question
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.)
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Correct Answer:
Apply elastic compression stockings.
Rationale:
Apply elastic compression stockings.
💠 Clients with quadriplegia are at very high risk for venous thromboembolism (VTE) due to immobility and venous stasis.
💠 Elastic compression stockings help promote venous return from the lower extremities by applying graduated external pressure.
💠 This reduces blood pooling in the legs and lowers the risk of deep vein thrombosis (DVT) and, subsequently, pulmonary embolism (PE).
💠 Use of stockings is an evidence-based prophylactic measure in immobilized patients.
💠 Therefore, applying compression stockings is an appropriate intervention to help prevent PE.
Perform passive range of motion exercises.
💠 Passive range of motion (PROM) maintains joint mobility and promotes circulation in clients who cannot move independently.
💠 PROM helps prevent venous stasis, which is a major risk factor for DVT in quadriplegic clients.
💠 Increased blood flow from limb movement reduces clot formation in deep veins.
💠 This intervention also helps prevent contractures and maintains musculoskeletal function.
💠 Thus, PROM is an important nursing action to help reduce PE risk in immobile clients.
Assess legs for redness.
💠 Regular assessment of the lower extremities for redness, warmth, swelling, or tenderness helps detect early signs of DVT.
💠 Early recognition of a DVT allows timely treatment to prevent clot migration to the lungs and development of PE.
💠 Ongoing monitoring is essential because quadriplegic clients may not feel pain due to sensory deficits.
💠 Assessment is part of VTE surveillance, a key role of the nurse in high-risk patients.
💠 Therefore, assessing the legs supports early detection and prevention of PE.
Place pillows under the client's knees when in bed.
💠 Placing pillows directly under the knees can compress blood vessels and reduce venous return from the lower extremities.
💠 This promotes venous stasis, which increases the risk of DVT formation.
💠 For PE prevention, positioning should avoid prolonged knee flexion and direct compression behind the knees.
💠 Elevation of legs should be done in a way that does not obstruct venous flow.
💠 Therefore, using pillows under the knees is contraindicated for PE prevention.
Massage the calves every shift.
💠 Massaging the calves in a client at risk for DVT is dangerous because it can dislodge an existing clot if one is present.
💠 A dislodged clot can travel to the pulmonary arteries and cause a pulmonary embolism, which may be fatal.
💠 Current guidelines specifically advise against calf massage in patients at risk for DVT or with suspected DVT.
💠 Instead, nurses should focus on prevention (compression, movement) and careful assessment.
💠 Thus, this action would increase, not decrease, the risk of PE.
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This question is from Custom Concept Quiz 2 which contains 40 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 5