A nurse is contributing to the plan of care for a client who is 2 days postoperative and reports pain in their calf. Which of the following actions should the nurse include?
Monitor the client's pulse oximetry.
Instruct the client to massage the calf gently.
Maintain the leg in a dependent position while in bed.
Apply a cold compress to the client's calf.
The Correct Answer is A
Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.
Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.
Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.
Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Prealbumin is a protein that is produced by the liver and is an indicator of the body's nutritional status. A low prealbumin level can indicate malnutrition, which is common in clients with COPD. Therefore, a dietary referral can help the client meet their nutritional needs and prevent further complications.
Correct Answer is A
Explanation
Giving change-of-shift report to a nurse outside the client's room helps to maintain client confidentiality. By discussing sensitive client information in a private and secure area, such as a designated report room or a location where other clients or visitors cannot overhear, the nurse ensures that the client's personal and medical information is not disclosed to unauthorized individuals.
Writing a client's diagnosis on the message board in the client's room can potentially expose sensitive medical information to anyone who enters the room, including visitors or other healthcare providers who are not directly involved in the client's care.
Discussing a client's prognosis with an assistive personnel who is caring for the client may violate the principle of need-to-know confidentiality. While it is important for healthcare team members to collaborate and communicate about client care, sensitive information should only be shared on a need-to-know basis.
Discarding worksheets containing client information in a wastebasket without proper shredding or disposal methods can potentially expose client information to unauthorized individuals who may come across the discarded documents. Proper procedures for document disposal, such as shredding or using secure disposal containers, should be followed to protect client confidentiality.
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