Question

A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care?

A: Initiate complete bed rest
.B: Massage the left lower leg three times a day.
C: Make sure the client's legs are elevated while in bed.
D: Apply cold compresses to the left lower leg every 2 hr.

Answer 1

For a client with left lower leg DVT, the nurse should ensure the client's legs are elevated in bed, potentially use graduated compression stockings, and avoid massaging the affected leg or applying cold compresses without specific instructions.

Step-by-step explanation:

A nurse planning care for a client with postoperative deep-vein thrombosis (DVT) should prioritize interventions that reduce the risk of the blood clot enlarging or dislodging and causing further complications. The nurse should not massage the affected leg, as this can dislodge the clot, and should not apply cold compresses routinely without a specific medical indication. Instead, the correct intervention is to make sure the client's legs are elevated while in bed. Elevating the legs helps to decrease venous pressure and promotes venous return, reducing the risk associated with DVT.

Other supportive measures include the use of graduated compression stockings to improve blood flow in the lower extremities and potentially the use of anticoagulant medications as prescribed by the healthcare provider. The nurse should monitor the client for signs of increased swelling or pain, as well as any indications of pulmonary embolism, which can be a serious complication of DVT.

Overall, the goal of these interventions is to prevent thrombus extension and reduce the risk of pulmonary embolism while minimizing discomfort and promoting healing.