If a positive Homans' sign is detected during assessment, the nurse should not perform this assessment again until a clot has been ruled out for which reason?
a. It may cause an embolus.
b. It may cause a thrombus.
c. It would cause the client emotional distress.
d. It would cause the client severe pain.
A
Nursing management focuses on improving the client's tissue perfusion, reducing pain and anxiety, and monitoring vascular status. Once the client has a positive Homans' sign, the assessment should not be performed again, to decrease the risk of causing an embolus. Nurses should also be alert to the prevention of any type of phlebitis or thrombosis in high-risk clients (e.g., postoperative clients and those receiving intravenous therapy).
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