The nurse is caring for a patient who develops a fever and reports right calf pain with a reddened and swollen calf. Which of these actions should the nurse take?
a. Massage the affected calf.
b. Place ice on the affected calf.
c. Place elastic stocking on right leg.
d. Measure bilateral calf circumference daily.
ANS: D
D. The calf should be measured bilaterally for comparison and documented daily to note changes. A, B, C. Massaging the calf is contraindicated, and antiembolism stockings are placed on the unaffected leg only during acute phase to prevent emboli. Warm-moist heat may be used for superficial thrombophlebitis.
You might also like to view...
The nurse is caring for an elderly client with a nursing diagnosis of Fluid Volume Deficit. Which of the following actions would yield the best indicator of the effectiveness of the nursing plan of care?
1. Pinch the skin on the back of the hand, and time how long it takes to return to normal. 2. Pinch the skin on the sternum, and time how long it takes to return to normal 3. Monitor the client's white blood cell count. 4. Monitor the client's intake and output.
After teaching a class about inborn errors of metabolism, the instructor determines that additional teaching is needed when the class identifies which of the following as an example of an inborn error of metabolism?
A) Galactosemia B) . Maple syrup urine disease C) Achondroplasia D) Tay-Sachs disease
The tympanic thermometer measures body temperature in the
A) mouth. B) nostril. C) rectum. D) ear.
A client who is trying to follow a low-fat eating pattern tells you that he or she has experienced diarrhea. You may want to find out whether he or she has
a. eaten foods made with the fat substitute carrageenan. b. eaten foods made with the fat substitute olestra. c. greatly increased intake of fish and seafood. d. developed essential fatty acid deficiency