Page 1727 - Saunders Comprehensive Review For NCLEX-RN

the artery, such as spasms and swelling of the skeletal
muscles.
8. Monitor for signs of swollen skeletal muscles such as
edema, pain on passive movement, poor capillary
refill, numbness, and muscle tenseness.
9. Maintain bed rest initially, with the client in a semi-
Fowler’s position.
10. Place a bed cradle on the bed.
11. Check the incision site for bleeding or hematoma.
12. Administer anticoagulants as prescribed.
13. Monitor laboratory values related to anticoagulant
therapy.
14. Instruct the client to recognize the signs and symptoms
of infection and edema.
15. Instruct the client to avoid prolonged sitting or
crossing the legs when sitting.
16. Instruct the client to elevate the legs when sitting.
17. Instruct the client to wear antiembolism stockings as
prescribed and how to remove and reapply the
stockings.
18. Instruct the client to ambulate daily.

19. Instruct the client about anticoagulant therapy

and the hazards associated with anticoagulants.
XX. Vena Cava Filter
A. Vena cava filter: Insertion of an intracaval filter (umbrella) that
partially occludes the inferior vena cava and traps emboli to
prevent pulmonary emboli (Fig. 52-14)
B. The filter is placed through a catheter placed in a large vein in the
neck or groin and advanced to the inferior vena cava.
C. Preoperative interventions: If the client has been taking an
anticoagulant, consult with the PHCP regarding discontinuation
of the medication preoperatively to prevent hemorrhage.
D. Postoperative interventions: similar to care after

embolectomy.
XXI. Hypertension

A. Description
1. For an adult (ages 18 years and older), a normal BP is a
systolic BP below 120 mm Hg and a diastolic pressure
below 80 mm Hg.
2. Elevated blood pressure is defined as a systolic BP
between 120 and 129 mm Hg and a diastolic BP below
80 mm Hg.
3. Hypertension (Stage 1) is defined as an SBP between
130 and 139 mm Hg or a diastolic BP between 80 and

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