Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and endothelial damage from surgeries or IV catheter placement.
VTE prophylaxis should be implemented in all hospitalized clients. Measures include:
Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1)
Application of compression devices or antiembolism stockings to limit venous stasis (Option 2)
Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4)
Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5)
Lifestyle and dietary measures that may help prevent GERD and associated symptoms include:
Weight loss because excessive abdominal fat may increase gastric pressure
Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1 and 5)
Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus
Sleeping with the head of the bed elevated (Option 4)
Discontinuing the use of tobacco products (Option 2)
Refraining from eating at bedtime and/or lying down immediately after eating
The nurse needs to quickly identify the signs and symptoms of myocardial infarction (eg, chest pain, diaphoresis, dyspnea, anxiety) and initiate interventions to preserve cardiac muscle. The nurse also recognizes that female and older clients may have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). The following are initial interventions in the emergency management of chest pain:
Assess airway, breathing, circulation (ABCs) (eg, vital signs, heart and lung sounds), and pain (eg, PQRST method) (Option 2)
Obtain diagnostics (eg, 12-lead ECG, cardiac markers, electrolytes, chest x-ray) (Options 3 and 4)
Apply oxygen if required (eg, SpO2 <90%, dyspnea)
Insert 2 large-bore IV lines and administer prescribed medications (eg, nitroglycerin, aspirin, morphine) (Option 1)
Initiate continuous cardiac monitoring
Prepare client for additional therapy (eg, percutaneous coronary intervention, thrombolytics)
Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspiration and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound.
Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excretion by the kidneys (Option 2).
For clients with increased intracranial pressure (ICP), the goal is to reduce ICP while managing the client's basic needs; however, many nursing activities increase client ICP. Nursing interventions to decrease ICP include:
Position head of bed to 30 degrees to promote venous return from the head, which will decrease cerebral edema. Elevating the head >30 degrees decreases blood pressure, which can decrease cerebral perfusion pressure (CPP); therefore, position the client to balance ICP and CPP.
Keep head and body midline and avoid extreme hip or neck flexion as this impedes venous drainage (Option 4).
Administer stool softeners to prevent straining to defecate (Option 1). Straining and coughing increase intrathoracic and intraabdominal pressure, which increase ICP.
Keep the client in a calm environment with minimal noise and disturbances (eg, dim lights, limit visitors) (Option 2).
Suction only when needed to maintain airway and for no longer than 10 seconds per suctioning pass (Option 5).
Reduce metabolic demands (eg, pain, seizures, hypoxia, fever). Treat fever aggressively (eg, acetaminophen) but avoid shivering.
Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection and bronchiolitis in infants and children, occurring primarily during the winter. It affects the ciliated cells of the respiratory tract, causing bronchiolar swelling and excessive mucus production. RSV in infants causes rhinorrhea, fever, cough, lethargy, irritability, and poor feeding. Severe RSV infection also causes tachypnea, dyspnea, and poor air exchange. Interventions are supportive, including:
Providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway (Option 5)
Elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance (Option 3)
Administering antipyretics to reduce fever and provide comfort (Option 1)
Initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake (Option 2)
Dyspnea (air hunger) is a common symptom in terminally ill clients. Dyspnea is subjective, and management depends on the client's clinical condition and reported symptoms. Initial interventions focus on decreasing respiratory effort and the perception of dyspnea, as well as relieving anxiety. Interventions for hospice clients include the following:
Administering opioids (eg, morphine, fentanyl), which are prescribed to relieve dyspnea (Option 2)
Providing low-flow oxygen by nasal cannula, which may provide psychological comfort and ease feelings of apprehension
Allowing frequent periods of rest to minimize exhaustion and dyspnea
Administering anxiolytics (eg, lorazepam) for anxiety associated with dyspnea
Placing a fan in the room to improve airflow near the client, which decreases the perception of dyspnea (Option 3)
Assisting with relaxation strategies (eg, music, guided imagery) (Option 4)