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
Related Questions
Correct Answer is C
Explanation
Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.
Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.
Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.
Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.
Correct Answer is A
Explanation
Wash hands with soap and water for 20 seconds: Washing hands with soap and water is the preferred method for hand hygiene in most situations, especially when hands are visibly soiled or contaminated with body fluids. The CDC recommends washing hands for at least 20 seconds, ensuring that all surfaces of the hands, including the back of the hands, between the fingers, and under the nails, are thoroughly cleaned.
Artificial nails should not be worn when performing direct client care: Artificial nails, including nail extensions and overlays, should be avoided when providing direct client care. The wearing of
artificial nails can increase the risk of bacterial colonization and make proper hand hygiene more challenging. Short, natural nails without nail polish are recommended for healthcare workers to ensure effective hand hygiene and reduce the risk of infection transmission.
Wear sterile gloves when in contact with body fluids: Sterile gloves are indicated when there is a need for an aseptic technique or when in contact with sterile body sites or invasive procedures.
However, for routine patient care and non-sterile procedures, non-sterile disposable gloves are typically sufficient. The use of gloves does not replace the need for proper hand hygiene before and after glove use.
Use alcohol-based cleanser when hands are visibly soiled: Alcohol-based hand sanitizers are effective in killing many types of germs when used correctly. However, they are not as effective when hands are visibly soiled or contaminated with body fluids. In such cases, washing hands with soap and water is recommended to ensure proper cleansing and removal of visible dirt or contaminants.
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