The nurse is preparing the client for discharge.

Exhibits

Which of the following statements indicate the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.

A. Administer aspirin for pain. Aspirin is an antiplatelet medication and is not appropriate for managing pain in a client with deep vein thrombosis (DVT). Additionally, aspirin can increase the risk of bleeding, especially in clients receiving anticoagulant therapy, so it should be avoided in this context.
B. Apply an ice pack to the affected extremity for 20 min every 2 hr. While ice packs may be helpful in reducing swelling, applying ice is generally not recommended for DVT because it may cause vasoconstriction and increase the risk of thrombosis. It’s more important to follow appropriate medical treatment guidelines for DVT management.
C. Massage the affected extremity every 4 hr. Massaging the affected extremity is contraindicated in cases of DVT, as it can dislodge the thrombus, potentially leading to a pulmonary embolism or other serious complications.
D. Initiate bed rest. Initiating bed rest is the appropriate action for a client with DVT. Bed rest helps prevent further clot formation and reduces the risk of complications. The healthcare provider will also typically order anticoagulant therapy to manage the condition safely. The client should avoid movement of the affected leg until medically advised otherwise.

A. Evaluate the need for the client to remain in mitten restraints. Assessing the necessity of restraints is a nursing responsibility that requires clinical judgment. Nurses must evaluate the client's condition and determine if restraints can be discontinued or if alternative measures are appropriate.
B. Assist the client with range-of-motion exercises of the hands. Assistive personnel (AP) can perform tasks that promote mobility, such as passive or active range-of-motion exercises. These exercises help prevent stiffness and maintain circulation in restrained extremities.
C. Determine the circulation status of the affected extremities every 2 hr. Assessing circulation involves evaluating capillary refill, skin color, temperature, and sensation, which requires nursing assessment skills. This task should be performed by a nurse rather than delegated to an AP.
D. Instruct the client's family about the purpose of mitten restraints. Educating the family on medical interventions falls within the nurse’s scope of practice. The nurse must explain the rationale, risks, and alternatives to ensure family members understand the need for restraints.