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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?

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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 Complete the physical assessment before notifying anyone
  2. B Massage the calf to reduce the pain
  3. C Apply a warm compress to the calf
  4. D 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

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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About this topic: Reduction of Risk Potential

Reduction of risk potential questions cover vital signs, lab values, diagnostic tests, and the complications to anticipate after procedures and surgery — recognising early signs and knowing what to report. This is one of 16 PN: Physiological Integrity questions on reduction of risk potential, each with a full explanation on a single study page.

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