The client is a 38-year-old female client who developed a pulmonary embolism and is currently in the Intensive Care Unit. The nurse in the Intensive Care Unit is interviewing the client and reviewing her history. Which of the following statements by the client or assessment findings are consistent with the client's increased risk for developing a pulmonary embolism? Standard Text: Select all that apply.
1. Client states, "I usually smoke two packs of cigarettes each day.".
2. Client states, "The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldn't.".
3. Client states, "I had an open appendectomy 4 days ago.". 4 cm incision noted to RLQ, staples intact, edges well-approximated
4. Client states, "I have taken oral contraceptives for the last 7 years.".
5. Client states, "I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care.".
1,2,3,4,5
Rationale 1: Client states, "I usually smoke two packs of cigarettes each day.". Cigarette smoke contains nicotine that produces vasoconstriction. Vasoconstriction of blood vessels increases the client's risk of developing a blood clot or a deep vein thrombosis.
Rationale 2: Client states, "The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldn't.". Ambulation following surgery is very important. Ambulation can reduce blood pooling in the calves and reduce the client's risk for clot formation. Immobility is a risk factor for blood clot formation.
Rationale 3: Client states, "I had an open appendectomy 4 days ago.". 4 cm incision noted to RLQ, staples intact, edges well-approximated . The client's history of a recent abdominal surgery increases the client's risk of developing a blood clot.
Rationale 4: Client states, "I have taken oral contraceptives for the last 7 years.". Oral contraceptive use is linked to increases risk of blood clot formation because of the way the medication works within the client's body.
Rationale 5: Client states, "I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care.". Muscle cramping and tenderness in the lower extremity are consistent with a deep vein thrombosis.
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