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.

Answer and Explanation

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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Correct Answer is D

Explanation

a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.

b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.

c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.

d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.

A. Tell the APS to stop the conversation. B. Document the event in the client's progress notes. C. Inform the client of the AP's actions. D. Submit an incident report to the risk manager.

Correct Answer is A

Explanation

Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.

When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.

The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.

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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?

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Naxlex Comprehensive Predictor Exams

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