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NCLEX · Reduction of Risk Potential

A client who has been on bedrest for 5 days reports sudden onset of unilateral calf pain, warmth, and swelling. What should the nurse do FIRST?

Correct answer

Stop any activity or calf manipulation; notify the RN immediately — these are classic symptoms of deep vein thrombosis (DVT); the risk with DVT is pulmonary embolism if the clot dislodges; massaging a DVT can cause embolisation

  1. A Massage the calf to reduce the pain
  2. B Stop any activity or calf manipulation; notify the RN immediately — these are classic symptoms of deep vein thrombosis (DVT); the risk with DVT is pulmonary embolism if the clot dislodges; massaging a DVT can cause embolisation
  3. C Apply a warm compress to the calf
  4. D Complete the physical assessment before notifying anyone

Why this is the answer

DVT RECOGNITION AND INITIAL RESPONSE: CLASSIC DVT SIGNS: Unilateral (one leg) calf pain; warmth; swelling (may see difference in leg circumference); redness; may be accompanied by low-grade fever; HOMAN'S SIGN (calf pain on dorsiflexion): historically taught but is UNRELIABLE and NOT recommended for diagnosis — but these symptoms together in a bedridden patient = high clinical suspicion; CRITICAL DANGER: If the thrombus (clot) dislodges from the calf vein, it travels up to the vena cava to the right heart to the pulmonary vasculature = PULMONARY EMBOLISM — potentially fatal; NEVER MASSAGE: Massaging, pressing, or squeezing the area of a suspected DVT can cause embolisation; PN PRIORITY: DO NOT TOUCH OR MANIPULATE THE CALF; IMMEDIATELY notify the RN; immobilize the leg; ANTICIPATED ORDERS: Duplex ultrasound of the leg (diagnostic); anticoagulation (heparin) if confirmed; elevation of leg with caution.
Source: NCLEX-PN Test Plan: Physiological — DVT Recognition and Initial Response

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