The nurse is caring for a patient who develops a fever and reports right calf pain with a reddened and swollen calf. Which action 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
The calf should be measured bilaterally for comparison and documented daily to note changes. A. B. C. Massaging the calf is contraindicated, and anti-embolism stockings are placed on the unaffected leg only during acute phase to prevent emboli. Warm-moist heat may be used for superficial thrombophlebitis.
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