A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?

Rationale for correct choices

• deep vein thrombosis (DVT): The client displays classic findings of DVT, including unilateral leg swelling, warmth, inflammation, and increased calf circumference. These findings, paired with a sedentary lifestyle and recent trauma to the leg, strongly indicate development of a thrombus in the affected extremity.

• Unequal leg circumference: The right calf measures 45.72 cm while the left measures 40.64 cm, showing significant unilateral swelling. A difference greater than 3 cm is strongly associated with DVT due to venous obstruction and impaired return, causing fluid accumulation and increased limb girth.

• Ultrasound results: The duplex ultrasound shows loss of venous compressibility and a thrombus in the right leg. These findings are diagnostic for DVT, confirming venous obstruction and establishing the cause of the client’s symptoms and leg swelling.

Rationale for incorrect choices

• undiagnosed fracture: A fracture would typically produce severe pain, deformity, or inability to bear weight, none of which are strongly present. The ultrasound confirms thrombosis, and the symptoms align more with venous obstruction than bone injury.

• cellulitis of a leg bone: Cellulitis usually presents with diffuse skin redness, warmth, and often fever. Although the leg is warm and inflamed, the presence of a venous thrombus on ultrasound and significant calf size difference more accurately support DVT rather than an infectious process.

• Difficulty walking: Difficulty walking can occur from many causes, such as arthritis or recent injury, and is not specific enough to confirm DVT. Objective findings like limb circumference and ultrasound imaging better demonstrate the underlying condition.

Rationale for correct choices

• Inspect the child's oropharynx: Vomiting bright red emesis after tonsillectomy indicates possible postoperative hemorrhage. Immediate inspection of the oropharynx allows the nurse to assess the source, amount, and severity of bleeding. Prompt identification of bleeding is critical to prevent hypovolemic shock and guide urgent interventions.

• Obtaining a set of vital signs: Vital signs provide objective data about the child’s hemodynamic status. Tachycardia, hypotension, or altered respiratory rate may indicate significant blood loss. Monitoring blood pressure, heart rate, and oxygen saturation helps determine the urgency of treatment and guides fluid resuscitation or other emergency measures.

Rationale for incorrect choices

• Place the child in a supine position: Placing the child supine could worsen bleeding or increase the risk of aspiration if emesis occurs. Standard care is to maintain the child upright or sitting forward to allow drainage and minimize airway compromise. Supine positioning is not appropriate immediately after post-tonsillectomy bleeding.

• Offer the child a red popsicle: Red-colored foods or drinks can mask the presence of ongoing bleeding, delaying recognition of hemorrhage. It is unsafe to offer red popsicles until bleeding is ruled out and the child is stable. Non-red liquids or clear fluids are safer during assessment.

• Encouraging the child to cough and deep breathe: While coughing and deep breathing are important for postoperative respiratory care, they are contraindicated if active bleeding is suspected. Coughing could dislodge clots and exacerbate hemorrhage. Airway safety and hemodynamic assessment take priority.

• Requesting a prescription for codeine: Administering codeine for pain is inappropriate in the presence of suspected bleeding because opioids can mask symptoms and depress respirations. Pain management should be secondary to stabilization and assessment of hemorrhage risk.