The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse?

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Clients with active DVT are at risk for developing a pulmonary embolism (PE). In the case of active DVT, the clot may become dislodged by massage or use of sequential compression devices on the affected extremity. The nurse would intervene immediately if a client was observed massaging the site, as this may actually trigger an embolism. (Option A) Mild fever would be expected with a diagnosis of DVT. (Option B) The client should not be kept immobilized out of a fear of dislodging the clot. Further immobility creates venous stasis and risks clot formation. Early ambulation is not shown to increase the risk for PE as previously believed. Ambulation is strongly encouraged after a full medical evaluation finds no risk of impending embolization. Bedrest with limb elevation may be prescribed initially for clients with severe pain and edema. (Option C) This is a normal respiratory rate in an adult. A respiratory rate of more than 20/min and symptoms of dyspnea could indicate a PE. Educational objective: DVT is best prevented by avoiding extended bed rest and encouraging ambulation even after the diagnosis. Massaging the site of inflammation is highly discouraged.

The Nurse Is Caring for a Client Recently Diagnosed with an Active