A nurse is contributing to the plan of care for a client who is 2 days postoperative and reports pain in their calf. Which of the following actions should the nurse include?
Monitor the client's pulse oximetry.
Instruct the client to massage the calf gently.
Maintain the leg in a dependent position while in bed.
Apply a cold compress to the client's calf.
The Correct Answer is A
Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.
Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.
Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.
Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.
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Related Questions
Correct Answer is C
Explanation
An incident report is a formal document used to report any unexpected or adverse events that occur during patient care. In this case, the administration of an incorrect dosage is an incident that should be documented in the incident report. The incident report serves as a record of the event and helps to ensure that appropriate follow-up actions are taken to prevent similar incidents in the future. It is important to note that an incident report is not part of the client's permanent medical record and is kept separate from other documentation.
The provider's progress notes, nursing care plan, and controlled substance inventory record are not appropriate locations to document this specific incident. The provider's progress notes are typically used to document the client's medical history, examination findings, treatment plans, and progress. The nursing care plan is a document that outlines the client's nursing diagnoses, goals, and interventions. The controlled substance inventory record is used to track and document the dispensing and administration of controlled substances, but it does not typically include incident reporting.
Correct Answer is A
Explanation
A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. The nurse should choose a room that is well-lit, sit facing the client, speak clearly and slowly, and ask a few questions at a time. Exaggerating lip movement while speaking is not recommended as it can be difficult for the client to read lips accurately. Additionally, sitting on the client's right side may not make a significant difference in their ability to hear.
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