A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action would be to?

1. A

   Assess for pain with plantarflexion

2. B

   Assess for edema and heat of the right leg

3. C

   Instruct him to rub the cramp out of his leg

4. D

   Elevate right lower extremity with pillows propped under the knee

Appeared in: NORCET 5 mains

Explanation

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• The patient's risk factors (age, obesity, hip surgery, atrial fibrillation) and symptom (leg cramp) are highly suggestive of a Deep Vein Thrombosis (DVT).
• The primary nursing response is to gather more assessment data to confirm this suspicion.
• Assessing for unilateral edema (swelling) and localized warmth (heat) are cardinal signs of DVT, caused by venous obstruction and inflammation.
• This assessment is a safe, non-invasive, and critical first step before notifying the provider.

Why Other Options Were Wrong

• Option A: Assessing for pain with plantarflexion (or dorsiflexion, known as Homans' sign) is an outdated practice. It has low diagnostic sensitivity and specificity and, more importantly, poses a risk of dislodging the thrombus.
• Option C: Massaging or rubbing a leg suspected of having a DVT is strictly contraindicated. This action can easily dislodge the clot, causing it to travel to the lungs and result in a life-threatening pulmonary embolism (PE).
• Option D: Placing pillows directly under the knee causes compression of the popliteal vein. This obstructs venous return from the lower leg, increases venous stasis, and elevates the risk of thrombus formation.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing assessment and immediate interventions for suspected Deep Vein Thrombosis (DVT) to guide bedside assessment, documentation, and the next nursing action.
• A nurse's ability to recognize DVT risk factors and early signs is critical for preventing pulmonary embolism (PE), a major cause of preventable death in hospitalized patients.
• Key nursing interventions for suspected DVT include: immediately notifying the healthcare provider, maintaining the patient on bed rest, and avoiding any manipulation of the affected limb.
• What if? If this same patient suddenly developed shortness of breath, chest pain, and anxiety, the nurse should suspect a pulmonary embolism has already occurred. This is a medical emergency requiring immediate intervention, including calling a rapid response team, applying oxygen, and preparing for emergency treatment.

How to Approach the Question

• First, analyze the patient's profile in the stem. Identify all risk factors for VTE (Venous Thromboembolism): age (74), obesity, major orthopedic surgery (hip), immobility (post-op day 8), and a prothrombotic condition (atrial fibrillation).
• Next, interpret the patient's chief complaint ('cramp in my leg') in the context of these high-risk factors. A leg cramp in this scenario is a classic warning sign for DVT.
• Evaluate each option based on principles of safety and evidence-based practice for suspected DVT.
• Eliminate options that are contraindicated or harmful. Rubbing the leg (can dislodge a clot) and propping a pillow under the knee (impedes venous flow) are dangerous and incorrect.
• Eliminate outdated practices. Assessing for Homans' sign (pain on dorsiflexion/plantarflexion) is no longer recommended.
• Select the option that represents the safest and most appropriate assessment step. Assessing for edema and heat are fundamental, non-invasive components of a DVT assessment.

Concept Tested & Keywords

• Concept Tested: Nursing assessment and immediate interventions for suspected Deep Vein Thrombosis (DVT).
• Stem keywords: 74-year-old, obese, open reduction and internal fixation, right hip, 8 days postoperative, atrial fibrillation, leg pain, cramp
• Lead-in keywords: appropriate nursing action
• Clinical cues: The combination of major orthopedic surgery, obesity, advanced age, and atrial fibrillation creates a very high-risk profile for DVT.
• Clinical cues: A new complaint of a 'cramp' in a post-surgical patient should immediately raise suspicion for DVT.

Question ID

Q6hFFexfIxe7ppmL03Ri9F

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Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 201-203

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 121-123