A nurse is providing care to a patient who had surgery 5 days ago. Today the patient's right calf is red, warm, swollen, and painful
Which interventions should the nurse implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Measure the circumference of both calves and compare the readings.
2. Place the patient on bed rest.
3. Collaborate with the patient's primary health care provider.
4. Place a pillow under the patient's knee on the affected side.
5. Palpate for pedal pulses bilaterally.
1,2,3,5
Rationale 1: It is important to measure both calves. This establishes a baseline measurement and also compares the unaffected calf with the affected calf.
Rationale 2: The patient should be maintained on bed rest until further treatment is done.
Rationale 3: The nurse should discuss this finding with the primary health care provider. The patient may be experiencing a deep vein thrombosis.
Rationale 4: Pressure under the knee should be avoided.
Rationale 5: The nurse should assess and compare the quality of the pedal pulses bilaterally.
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