A nurse is preparing to administer digoxin to a client who has left-sided heart failure.
Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).

Choice A rationale:

The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.

Choice B rationale:

Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.

Choice C rationale:

Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.

Choice D rationale:

Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.

Choice A rationale:

The nurse should not instruct the client to rest with the legs above heart level. While elevating the legs can be helpful for managing symptoms of peripheral artery disease (PAD), it is not a suitable choice for older adults, especially those with heart conditions. It can put additional strain on the heart and may not be appropriate for all clients. Elevation of the legs should be done with caution and under healthcare provider guidance.

Choice B rationale:

The nurse should not advise the client to wear antiembolic stockings during the day. Antiembolic stockings, also known as compression stockings, are primarily used for venous insufficiency and the prevention of deep vein thrombosis (DVT). They may not be effective or necessary for the management of PAD. It's important to tailor the instructions to the specific condition, and in the case of PAD, other strategies may be more appropriate.

Choice C rationale:

The correct answer is choice C. The nurse should instruct the client to adjust the thermostat so that the environment is warm. This is an important recommendation for clients with PAD because keeping the extremities warm can help improve circulation and reduce symptoms. Cold environments can exacerbate the vasoconstriction associated with PAD, leading to more discomfort. Maintaining a warm environment is a simple and effective measure for symptom management.

Choice D rationale:

The nurse should not recommend applying a heating pad on a low setting to help relieve leg pain. While heat can provide temporary relief for muscle pain, it may not be the best option for clients with PAD. Applying heat directly to the affected area can sometimes lead to burns or skin damage, especially in older adults who may have decreased sensation. Heat should be used cautiously, and other methods like keeping the environment warm are preferred.