Difficulty: Medium
Average Score: 80%
Simulated
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?
Correct answer
C
Rationale
The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options 1 and 2 could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.