A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

(A) Treatment: While treatment is an important part of the client’s information, it is typically included in the “Recommendation” component of ISBARR, where the nurse would discuss the recommended treatment plan.

(B) List of medications: The list of medications a client is taking is crucial information, but it is usually included in the “Background” component of ISBARR, which provides context about the client’s medical history and current medications.

(C) Medical condition: This is the most appropriate answer. The “Situation” component of ISBARR is meant to provide a brief overview of the client’s current situation, which includes their current medical condition or reason for admission.

(D) Vital signs: Vital signs are typically included in the “Assessment” component of ISBARR, where the nurse would discuss the results of their assessment of the client, including vital signs.

A. Verify that the client's valuables have been secured:

While securing the client's valuables is important for their safety and security during hospitalization, it does not directly address the prevention of postoperative complications.
B. Discuss a discharge date with the client:

Discussing a discharge date is part of discharge planning but does not directly address the prevention of postoperative complications.
C. Inform the client about the need for sequential compression devices:

Sequential compression devices (SCDs) are mechanical devices that help prevent venous stasis and deep vein thrombosis (DVT) by promoting circulation in the lower extremities. They are commonly used in surgical patients to reduce the risk of blood clots and related complications.
D. Review the facility's visitation policy with the client and family:

Reviewing the facility's visitation policy is important for ensuring that the client and family understand the rules and regulations regarding visitors. While visitor policies contribute to the overall well-being of the client during their hospital stay, they do not directly address the prevention of postoperative complications like the use of sequential compression devices does.