A nurse is caring for a postpartum client with thromboembolic. When planning care to prevent the complication of pulmonary embolism, the nurse plans specifically to?

1. A

   Enforce bedrest

2. B

   Monitor the vital signs frequently

3. C

   Assess the breath sound frequently

4. D

   Administer and monitor anticoagulant therapy as prescribed

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

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• The primary intervention to prevent a deep vein thrombosis (DVT) from becoming a pulmonary embolism (PE) is administering anticoagulant medication.
• Anticoagulants work by stabilizing the existing clot, preventing it from growing larger (propagation), and stopping new clots from forming.
• This stabilization significantly reduces the risk that a piece of the clot will break off, travel through the bloodstream, and lodge in the pulmonary arteries.
• This is a direct, proactive treatment, whereas other options focus on monitoring or have a secondary role.

Why Other Options Were Wrong

• Option A: Enforcing strict bedrest is generally not recommended as it promotes venous stasis, which is a major risk factor for the formation and extension of thrombi.
• Option B: Monitoring vital signs is a crucial assessment for the early detection of a PE (e.g., tachycardia, tachypnea, hypotension), but it does not prevent the clot from embolizing.
• Option C: Assessing breath sounds is an important respiratory assessment to detect signs of a PE (such as crackles or diminished lung sounds), not to prevent its occurrence.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prevention of pulmonary embolism in a client with deep vein thrombosis (DVT) to guide bedside assessment, documentation, and the next nursing action.
• Nurses are responsible for the safe administration of anticoagulants, monitoring for therapeutic effects via lab results (aPTT, INR), and vigilantly observing for the primary adverse effect: bleeding.
• Patient education is a critical nursing role. The nurse must teach the client the signs of PE (sudden chest pain, shortness of breath) and bleeding (tarry stools, unusual bruising) and emphasize the importance of adherence to medication and follow-up lab tests.
• What if? If the postpartum client was actively hemorrhaging, anticoagulant therapy would be contraindicated. In this emergency scenario, an inferior vena cava (IVC) filter might be surgically placed to physically trap clots and prevent them from reaching the lungs.

How to Approach the Question

• First, identify the key concept in the question: the goal is to prevent a complication (PE) from an existing problem (thromboembolism).
• Analyze each option to determine its primary purpose: is it for prevention, detection, or management?
• Recognize that monitoring vital signs and assessing breath sounds are actions for detection or assessment, not prevention. This eliminates options B and C.
• Compare the remaining options. Enforcing bedrest can worsen venous stasis, a risk factor for clots. Administering anticoagulants is the direct medical treatment to stop clot progression.
• Conclude that the most specific and effective preventative action is the administration of anticoagulant therapy.

Concept Tested & Keywords

• Concept Tested: Prevention of pulmonary embolism in a client with deep vein thrombosis (DVT).
• Stem keywords: postpartum client, thromboembolic, pulmonary embolism, prevent complication
• Lead-in keywords: plans specifically to
• Clinical cues: The patient has an existing thromboembolic condition, so the goal is secondary prevention (preventing a complication) rather than primary prevention (preventing the initial clot).
• Negative lead-in flag: false

Question ID

QYbHUT8574POmPgOV58R0V

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 2 p. 13-15

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 201-203