The postpartum client is diagnosed with thrombophlebitis in the right leg. Which assessment finding requires immediate intervention by the nurse?
1. Acute pain
2. Redness
3. Chest pressure
4. Edema
3
Explanation:
1. Acute pain often accompanies diagnosis of thrombophlebitis. While the pain is important and should be addressed, this finding does not require priority nursing intervention.
2. Redness often accompanies diagnosis of thrombophlebitis. While the redness should be noted and monitored, this does not require priority nursing intervention.
3. A sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention by the nurse.
4. Edema often accompanies diagnosis of thrombophlebitis. While the swelling should be noted and monitored, this does not require priority nursing intervention.
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