Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
7. A 34-year-old client, who is gravida 6, para 4, delivered a healthy infant at full term about 18 hours ago. She reports a sharp pain in her left calf while walking to the bathroom. A nurse assesses the client's left calf, which has a confined area of redness, warmth, and tenderness. Which nursing actions are appropriate for this client's nursing care? Select all that apply.
. Instruct the client to massage the calf to relieve the pain and tenderness.
. Encourage the client to ambulate to increase circulation.
. Administer anticoagulation therapy as ordered.
. Elevate the affected extremity to promote venous blood flow.
. Have the client sit up at the side of the bed with affected leg dangling.
Test-Taking Tip
The main goal of DVT treatment is to prevent clots from traveling to major organs and causing mortality and morbidity. Eliminate those options that are not consistent with this goal.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because it is contraindicated to massage the site of the deep vein thrombosis (DVT). Massaging the calf can dislodge the clot and lead to an embolism. Answer 2 is correct because the client should be encouraged to ambulate in addition to receiving anticoagulant therapy, since bedrest itself may enhance venous stasis. Answer 3 is correct because the most important goal is to prevent a pulmonary embolism or its recurrence. Incidence of pulmonary embolism depends on whether or not DVT is adequately treated with anticoagulant therapy. Answer 4 is correct because elevation of the affected extremity is important initially because it promotes venous return and decreases edema. Answer 5 is incorrect because sitting with legs dependent is contraindicated because it increases stasis and edema.