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Difficulty: HardBasic Care and Comfort

An adult client is restricted to bed rest due to an acute deep venous thrombosis (DVT) in the right calf. The client reports dull, aching leg pain and requests a bed bath. When providing hygiene and comfort measures, which action by the practical nurse is the priority?

  1. A
    Wash the affected extremity using firm, upward strokes from the ankle toward the thigh to stimulate venous blood flow.
  2. B
    Position a tightly rolled blanket directly behind the right knee joint to relieve musculoskeletal tension while the client is supine.
  3. Maintain the affected extremity supported on a soft wedge cushion above the level of the heart during the bathing process.Answer
  4. D
    Encourage the client to independently perform active range-of-motion exercises with the right leg to minimize joint stiffness.

Answer

Maintain the affected extremity supported on a soft wedge cushion above the level of the heart during the bathing process.
Elevating the affected extremity above the level of the heart uses gravity to passively promote venous return. This safely reduces tissue edema and alleviates the client's aching discomfort without mechanically disturbing the acute thrombus. It is the gold standard for basic comfort and safety when caring for a client with a deep vein thrombosis.

Step-by-Step Solution

1
Identify the client's primary diagnosis and associated risks.
The client has an acute DVT in the right calf, presenting a severe risk for thrombus dislodgement and subsequent pulmonary embolism.
Understanding the underlying pathology is essential before performing any physical manipulation during hygiene care.
2
Evaluate the proposed hygiene and positioning interventions against safety contraindications.
Massaging the leg (firm upward strokes), applying popliteal pressure (blanket behind the knee), and performing active range-of-motion on the affected leg are identified as dangerous.
These actions increase mechanical pressure or muscle contraction around the vein, which can break the acute clot loose into the bloodstream.
3
Select the intervention that provides basic comfort and safety.
Elevating the leg on a wedge pillow is chosen as the safest and most effective action.
Elevation uses gravity to reduce venous congestion and localized pain without applying direct physical manipulation to the affected calf.

Key Concept

Basic Care and Immobility Precautions for DVT
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Topics

Basic Care and Comfort

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