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.
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Related Questions
Correct Answer is A
Explanation
This statement should be included in the change-of-shift report because it provides vital information about the patient’s condition and any changes that have occurred to the patient during the shift.
Statement B is wrong because it does not provide relevant information about the patient’s current condition or changes that have occurred during the shift. Statement C is wrong because it does not provide relevant information about the patient’s medical condition. Statement D is wrong because it does not provide new information about changes that have occurred during the shift.
Change-of-shift reports are key to inpatient care because they provide vital information about and responsibility for the patient from the off-going provider to the on-coming provider.
Correct Answer is B
Explanation
Furosemide is a diuretic medication that helps remove excess fluid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is effective is an increase in urinary output. This can help reduce fluid buildup in the body, which can improve symptoms of heart failure.
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