A patient has developed severe postsurgical muscle weakness in the lower extremities after the removal of a brain tumor. The nurse takes which initial intervention to minimize the patient's risk of developing a deep vein thrombosis (DVT)?
1. Ask the patient questions to determine if there is a history of DVT.
2. Add regular leg massages to the patient's care plan.
3. Instruct the patient to perform leg exercises at least twice daily.
4. Apply well-fitted antiembolism hose.
4
Rationale 1: Determining whether the patient has a history of DVT is not the priority intervention.
Rationale 2: Massaging the legs is not an appropriate nursing intervention and may result in serious injury to the patient.
Rationale 3: The patient with this level of muscle weakness is not capable of performing leg exercises.
Rationale 4: The use of antiembolism hose or pneumonic stockings is highly recommended, and they should be applied as soon as possible. The hose must fit correctly to be effective.
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