NR 304 HEALTH ASSESMENT: SIM QUESTIONS & ANSWERS
1) Based on what you’ve learned about the nursing process, describe one
applicable nursing diagnosis, treatments, and nursing considerations for this
diagnosis?
Nursing diagnosis:
Ineffective tissue perfusion
Pain related to inflammation
Risk for pulmonary embolism
Nursing treatment:
Control thrombus development, prevent complications and relieve pain. Treatment
should include anticoagulants to prevent clotting. Pain medications to relieve the
pain.
Nursing considerations:
To prevent Dvt performing ROM while pt is in bed rest, remain alert for sings of
pulmonary embolus, such as sudden sharp chest pain, that’s worse during
inspiration, crackles, dyspnea, sudden change in mental status, hypotension,
restlessness, closely monitoring the anticoagulant therapy to prevent complications
and internal bleeding. Measure the circumference of the right calf daily and
1) Based on what you’ve learned about the nursing process, describe one
applicable nursing diagnosis, treatments, and nursing considerations for this
diagnosis?
Nursing diagnosis:
Ineffective tissue perfusion
Pain related to inflammation
Risk for pulmonary embolism
Nursing treatment:
Control thrombus development, prevent complications and relieve pain. Treatment
should include anticoagulants to prevent clotting. Pain medications to relieve the
pain.
Nursing considerations:
To prevent Dvt performing ROM while pt is in bed rest, remain alert for sings of
pulmonary embolus, such as sudden sharp chest pain, that’s worse during
inspiration, crackles, dyspnea, sudden change in mental status, hypotension,
restlessness, closely monitoring the anticoagulant therapy to prevent complications
and internal bleeding. Measure the circumference of the right calf daily and
