A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

Rationale for correct choices

• Deep vein thrombosis: The client presents with unilateral right lower extremity swelling, warmth, and pain below the knee, all of which are hallmark signs of deep vein thrombosis (DVT). Postoperative immobility, recent hysterectomy, obesity, age, and history of smoking significantly increase the risk of venous thromboembolism.

• Check for pedal pulses and signs of ischemia: Assessing pedal pulses and ischemic changes ensures that arterial circulation remains intact while monitoring for potential complications. This evaluation is essential prior to initiating interventions, including anticoagulation or mechanical therapies, to prevent tissue damage or further vascular compromise.

• Request a prescription for a lower-extremity Doppler flow study: A Doppler ultrasound is the standard diagnostic test to confirm DVT. Timely imaging guides the initiation of anticoagulation therapy and helps prevent clot propagation or embolization. Confirming the diagnosis is crucial for implementing safe and effective treatment strategies.

• Signs of bleeding after anticoagulation initiation: Monitoring for bleeding is essential because anticoagulants are the mainstay of DVT treatment. The client is at risk for hemorrhage due to medication or underlying surgical recovery, and early recognition of bleeding complications prevents serious morbidity.

• PT/INR and platelet count: These laboratory parameters are critical to monitor coagulation status and platelet function, particularly if anticoagulation therapy (e.g., heparin or warfarin) is prescribed. Tracking these values ensures therapeutic effectiveness while minimizing the risk of bleeding complications.

Rationale for incorrect choices

• Cellulitis: Cellulitis typically presents with diffuse erythema, tenderness, and possible fever. While the client has warmth and swelling, the unilateral presentation and postoperative risk factors point toward a thrombotic event rather than a bacterial infection. WBC is only slightly elevated, and systemic signs of infection are minimal.

• Muscle strain: Muscle strains usually occur after acute trauma or overuse and often involve localized pain without significant swelling or warmth. The client’s symptoms developed postoperatively without recent exertion, making a strain unlikely.

• Heart failure: Heart failure often presents with bilateral edema, pulmonary congestion, dyspnea, and elevated BNP. The client’s edema is unilateral and below the knee, with clear lungs and normal oxygen saturation, which does not support a diagnosis of heart failure.

• Implement rest, ice, elevation, compression (RICE): RICE is appropriate for musculoskeletal injuries such as strains or sprains but is not recommended for DVT, as compression and manipulation of the affected extremity could dislodge the clot and precipitate a pulmonary embolism.

• Assess for Homan's sign: Homan’s sign (pain on dorsiflexion of the foot) is not a reliable or specific indicator of DVT and is generally discouraged as a primary assessment tool. Clinical observation and Doppler imaging are preferred.

• Request a prescription for IV furosemide: Furosemide is used to treat fluid overload in conditions like heart failure, not DVT. The client’s symptoms are localized, and there is no evidence of systemic fluid retention requiring diuretics.

• Brain natriuretic peptide (BNP) levels: BNP is used to assess for heart failure. This client has no signs of pulmonary congestion or systemic fluid overload, so BNP monitoring is not indicated in this scenario.

• ECG changes: While ECG is useful for detecting cardiac arrhythmias, it does not provide information regarding lower-extremity venous thrombosis. The client’s cardiac history does not suggest arrhythmia as the primary concern at this time.

• Temperature: The client’s temperature is normal, and there is no indication of systemic infection, so monitoring temperature does not directly assess the progression of DVT.

Rationale:

A. A client who moved to an apartment located on higher ground than her previous home: Relocating to a safer area demonstrates adaptive coping and proactive problem-solving. It does not indicate symptoms of posttraumatic stress disorder (PTSD) and does not require a referral for mental health assessment.

B. A client who has frequent nightmares about the hurricane: Recurrent intrusive thoughts or nightmares about a traumatic event are hallmark symptoms of PTSD. This client should be referred for further evaluation and possible treatment.

C. A client who expresses a realization that life will not return to the way it was before the hurricane: Accepting permanent changes after a disaster reflects normal adjustment and resilience. This insight alone does not suggest PTSD.

D. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common PTSD symptom. This client should be referred for assessment to address potential social and emotional impairments.

E. A client who describes having persistent feelings of anger about the hurricane: Persistent irritability or anger is another symptom associated with PTSD. Referral is appropriate to evaluate for underlying trauma-related disorder and provide supportive interventions.