A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine.
Which of the following findings should the nurse expect?

Choice A rationale:

Applying a cold compress to the client's calf is not the priority in this situation. The client is reporting pain in the calf, which could be indicative of deep vein thrombosis (DVT), a potentially serious condition. Monitoring the client's oxygen saturation (pulse oximetry) is a more appropriate action to assess for possible DVT complications, such as a pulmonary embolism.

Choice B rationale:

Monitoring the client's pulse oximetry is the correct action in this scenario. Pain in the calf can be a symptom of DVT, which can lead to reduced blood flow and potential oxygenation issues. Monitoring the client's oxygen saturation levels can help identify any oxygenation problems early.

Choice C rationale:

Instructing the client to massage the calf gently is not recommended in this situation, as it may dislodge a clot if DVT is present. Massaging the calf can be harmful and is contraindicated when DVT is suspected.

Choice D rationale:

Maintaining the leg in a dependent position while in bed is not a recommended action in this case. Elevating the leg can help reduce swelling and improve venous return, but it should be done cautiously, especially if DVT is suspected. Monitoring the client's condition and oxygen saturation takes precedence.

Choice A rationale:

Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.

Choice B rationale:

An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.

Choice C rationale:

Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.

Choice D rationale:

Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.