A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

A. Measuring gastric residual volumes every 4 hours is important to assess the client’s tolerance to the feeding and prevent aspiration.
B. Flushing with saline should only be done as necessary for medication administration and not routinely unless specified by protocol.
C. The rate of feeding should be adjusted based on the client’s tolerance and not increased arbitrarily.
D. The head of the bed should be maintained at 30–45° to reduce the risk of aspiration.

Most Likely Condition: Deep Vein Thrombosis (DVT)
The client has multiple risk factors for developing a Deep Vein Thrombosis (DVT
• Recent surgery: The client is 2 days postoperative following a hysterectomy, which increases the risk of blood clots.
• Obesity: The client’s weight is 121.3 kg (267.4 lb), which significantly increases the risk of DVT
due to poor circulation and reduced mobility.
• Physical inactivity: The client has not yet ambulated much post-surgery due to significant pain, leading to stasis of blood in the lower extremities, which can increase the risk of clots.

• Smoking history: Smoking can damage blood vessels and increase clotting risk.
• Noncompliance with sequential compression devices (SCDs): The client reports that SCDs "hurt too much," and as a result, they are not wearing them. SCDs are a key prevention strategy against DVT, so nonuse of them further increases the risk.

Actions to Take

Check for pedal pulses and signs of ischemia:
DVT can lead to impaired circulation and ischemia in the affected limb. The nurse should assess for pedal pulses and signs of ischemia (e.g., coldness, swelling, pallor) to evaluate the extent of blood flow to the lower extremities. Early detection of impaired circulation can prevent complications like tissue damage.
Request a prescription for a lower-extremity Doppler flow study:
A Doppler ultrasound is the gold standard for diagnosing DVT. This non-invasive test uses sound waves to assess blood flow and detect clots. It should be ordered if the nurse suspects a DVT, especially with the client’s high risk factors.

Parameters to Monitor

Signs of bleeding after anticoagulation initiation:
If the client is diagnosed with a DVT, anticoagulants (e.g., heparin, warfarin, or enoxaparin) are often prescribed to prevent the clot from growing or migrating. The nurse needs to monitor for signs of bleeding (e.g., unusual bruising, bloody stools, or hematuria) as anticoagulant therapy increases bleeding risk.
Temperature:
Fever can be an indicator of infection or inflammation. If a DVT becomes complicated by phlebitis (inflammation of the vein) or if the clot is large or causes an infection, the client may develop a fever. Regular temperature monitoring is essential for detecting early signs of infection or complications related to DVT.

Rationale for incorrect conditions;
Muscle strain: While muscle strain can occur, the client’s presentation and risk factors (recent surgery, immobility, obesity) align more with DVT. Muscle strain is usually associated with localized pain, whereas DVT often presents with swelling, pain, and redness in the lower extremity, and potentially warmth.
Cellulitis: This is an infection of the skin and underlying tissues, typically presenting with redness, swelling, and warmth. The client does not exhibit these symptoms, and there’s no indication of an infection in the notes.
Heart failure: Heart failure can cause fluid retention, which leads to swelling in the extremities, but the
client’s vital signs (e.g., normal BP, heart rate, and respiratory rate) do not suggest heart failure. Additionally, the client does not report symptoms such as shortness of breath or chest pain.