A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority?

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11ecbb05_c950_5bf7_b433_21501ea43d30_MD0009_00 This client with a tender calf that feels warm to the touch is exhibiting signs and symptoms of a possible deep vein thrombosis (DVT). Additionally, the client has several risk factors for DVT (age >60, being hospitalized and in bed for 3 days). The nurse will need to notify the health care provider (HCP) immediately. However, prior to this, the nurse must perform a thorough assessment of the client to report to the HCP. The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. (Options A, B, and C) These are all assessments that the nurse should collect to report to the HCP but are not as high of a priority or as relevant to the specific situation that the client is currently experiencing. Educational objective: The nurse that suspects DVT should perform a thorough neurovascular assessment of the client's extremities, including presence and quality of DP and PT pulses, temperature of extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. The findings should be reported immediately to the HCP.

A 62-Year Old Client Was Admitted to the Telemetry Unit