A nurse is assisting in the care of a client

Which of the following interventions should the nurse plan to implement? Select all that apply.

A) Administer aspirin for pain: Aspirin is an anticoagulant and should be avoided in clients receiving other anticoagulant therapy, especially in the context of deep vein thrombosis (DVT). Using aspirin could increase the risk of bleeding and complications. Therefore, it is not appropriate for pain management in this situation.

B) Initiate bed rest: While rest may be indicated for comfort and to reduce the risk of further clot formation, complete bed rest is generally not recommended in the management of DVT unless specifically directed by the healthcare provider. Early ambulation and the use of compression devices or stockings are typically encouraged to promote circulation and reduce the risk of complications, such as pulmonary embolism.

C) Massage the affected extremity every 4 hr: Massaging the affected extremity is contraindicated in a client with DVT, as it can dislodge the clot and increase the risk of a pulmonary embolism or other complications. It is important to avoid any direct manipulation of the affected limb to prevent causing harm.

D) Apply an ice pack to the affected extremity for 20 min every 2 hr: Applying an ice pack is
an appropriate intervention for reducing swelling and providing comfort in the case of a DVT. The cold therapy helps to constrict blood vessels, reduce inflammation, and relieve pain. This intervention should be done carefully to avoid skin damage, and the nurse should monitor the skin for signs of injury.

A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.