A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

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. "Your provider understands your illness and is acting according to your best interests.": This statement does not address the client’s concerns and may minimize their feelings. It shifts focus away from the client’s perspective rather than supporting their right to express concerns about discharge timing.

B. "I know you will be able to recover faster at home.": This statement assumes the provider’s decision is correct and discourages the client from expressing concerns. It does not advocate for the client or ensure their voice is heard in care planning.

C. "I will tell the provider about your concerns.": Communicating the client’s concerns to the provider demonstrates client advocacy. The nurse acts on behalf of the client to ensure their preferences, questions, and safety needs are considered in the discharge decision.

D. "I will contact your insurance company to see if they will pay for you to be here longer.": While insurance involvement may be relevant, the primary role of the nurse as an advocate is to convey the client’s concerns to the healthcare team rather than directly managing insurance coverage issues.