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.”

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 is to:
A . Assess for pain with plantiflexion
B . Assess for edema and heat of the right leg
C . Instruct him to rub the cramp out of his leg
D . Elevate right lower extremity with pillows propped under the knee

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Answer: B

Explanation:

(A) Calf pain with dorsiflexion of the foot (Homans’ sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition.

(B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall.

(C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus.

(D) A pillow behind the knee can be constricting and further impair blood flow.