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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.
Correct Answer is ["B","E"]
Explanation
b. Ensure the chest tube remains below the level of the client's chest.
e. Reinforce loose dressing around the tube.
When managing a chest tube, it is important for the nurse to ensure that the chest tube remains below the level of the client's chest¹. This helps to prevent air from entering the pleural space and allows for proper drainage of fluid. The nurse should also reinforce any loose dressing around the tube to maintain a secure seal¹.
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