Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
26. A client reports sharp pain in the calf of the left leg when walking to the bathroom. A nurse notes that the leg has a confined area of warmth, tenderness, and redness. Which nursing action is most appropriate for this client?
. Encouraging the client to ambulate to increase circulation.
. Instructing the client to massage the affected area to relieve the tenderness.
. Applying cold packs to the affected area to decrease inflammation.
. Elevating the affected extremity to promote venous blood flow.
Test-Taking Tip
Eliminate the responses that make the condition of thrombophlebitis worse (i.e., massage, Answer 2; ambulate, Answer 1 ). See key phrase in the correct option: "promote venous blood flow."
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because a client with symptoms of thrombophlebitis should be placed on bedrest, not encouraged to ambulate. Answer 2 is incorrect because this client has symptoms of thrombophlebitis; massaging the leg can break the thrombus from the venous wall and cause an embolus. Answer 3 is incorrect because local application of heat is one of the treatments for superficial thrombosis, not ice, which constricts blood flow. Answer 4 is correct because this client has a superficial thrombophlebitis. Elevation of the affected extremity, a few days of bedrest, and local application of heat are often all that is needed to treat superficial thrombophlebitis.