Medical Surgical Peripheral Vascular Disease #7

Question

The nurse is caring for a post-surgical client. During the assessment, the client complains of sudden onset of pain to the right lower leg. The right lower leg is swollen, reddened, and warm to touch. What is the most appropriate action by the nurse?

Answers

  1. Administer 10,000U dose of subcutaneous heparin followed by continuous IV Heparin.
    • Rationale:

      This answer is not correct because although the nurse may expect to administer heparin or other anticoagulant, nevertheless, no medication should be administered without the provider’s prescription. The symptoms should be reported to the health care provider immediately. This is a very serious condition since there is a high risk of this DVT moving and traveling in the bloodstream to the lungs, causing a pulmonary embolism, a life-threatening condition that can cause immediate death.

  2. Inform the physician that the client has signs and symptoms of venous thrombosis.
    • Rationale:

      This answer is correct because venous thrombosis or deep vein thrombosis (DVT) has symptoms that include unilateral calf, thigh, or ankle pain, that is red, swollen, and warm to touch. These symptoms should be reported to the health care provider immediately. This is a very serious condition since there is a high risk of this DVT moving and traveling in the bloodstream to the lungs, causing a pulmonary embolism, a life-threatening condition that can cause immediate death.

  3. Ambulate the client immediately to restore circulation.
    • Rationale:

      This answer is not correct because ambulating may cause the clot to break off and enter the circulation. Venous thrombosis or deep vein thrombosis (DVT) has symptoms which include unilateral calf, thigh, or ankle pain, that is red, swollen, and warm to touch. These symptoms should be reported to the health care provider immediately.

  4. Place heating pad to right leg for 15 minutes followed by smaller size compression stockings.
    • Rationale:

      This answer is not correct because placing heat followed by tight compression stockings is not a priority action, and may cause the clot to break off. Venous thrombosis or deep vein thrombosis (DVT) has symptoms which include unilateral calf, thigh, or ankle pain, that is red, swollen, and warm to touch. These symptoms should be reported to the health care provider immediately.

Overview

Venous thrombosis or deep vein thrombosis (DVT) has symptoms that include unilateral calf, thigh, or ankle pain, that is red, swollen, and warm to touch. These symptoms should be reported to the health care provider immediately.

Explanation

Learning Outcomes

Venous thrombosis or deep vein thrombosis (DVT) occurs when a clot develops in a deep vein, generally in the leg. This is a very serious condition since there is a high risk of this DVT moving and traveling in the bloodstream to the lungs, causing a pulmonary embolism, a life threatening condition that can cause immediate death. Venous thrombosis or deep vein thrombosis (DVT) has symptoms that include unilateral calf, thigh, or ankle pain, that is red, swollen, and warm to touch. These symptoms should be reported to the health care provider immediately.

Test Taking Tip

Unilateral is a keyword for symptoms associated with a deep vein thrombosis (DVT). Watch for that word!

Video Rationale