The nurse is caring for a patient with an intermediate risk for developing a pulmonary embolism. Which of the following interventions would be indicated for this patient?
1. bedrest
2. intravenous fluids
3. preventative anticoagulant therapy and antiembolism stockings
4. strict measurement of intake and output
3
Rationale: Prevention of pulmonary embolism is a priority of nursing care in all high-risk patients. Since the major cause of pulmonary embolism is deep vein thrombosis, management should center on interventions to prevent a deep vein thrombosis. Preventive measures include: early ambulation, anticoagulant therapy, antiembolism stockings, compression boots, elevation of injured leg above heart level, and frequent assessment of injured leg for signs of a deep vein thrombosis for early recognition and treatment. Deep vein thrombosis may not have any signs or symptoms; however, when present they may include unilateral leg swelling, pain or tenderness, or cramping. Bedrest would not help prevent the onset of a deep vein thrombosis. Intravenous fluids and strict measurement of intake and output would also not prevent the onset of a deep vein thrombosis.
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