Question

The client diagnosed with a myocardial infarction is on bed rest. The unlicensed nursing assistant is encouraging the client to move the legs. Which action should the nurse implement?

1. Instruct the assistant to stop encouraging the leg movements.
2. Report this behavior to the charge nurse as soon as possible.
3. Praise the nursing assistant for encouraging the client to move legs.
4. Take no action concerning the nursing assistant's behavior.

Answer 1

The nurse should ensure that leg movements are part of the care plan for a myocardial infarction patient on bed rest and, if so, praise the assistant for preventing immobility complications.

Step-by-step explanation:

If a client diagnosed with a myocardial infarction is on bed rest, and a nursing assistant is encouraging the client to move the legs, the nurse should assess the situation and the patient's care plan before taking action. Leg movements can help prevent venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), which are potential complications of being immobile. If the patient is medically cleared for leg movements and they are within the care plan's guidelines, the nurse should then praise the nursing assistant for encouraging activity that could prevent complications. However, the nurse should always ensure that the activities align with the patient's prescribed care plan.