A patient, who had a hysterectomy 2 days ago, reports tenderness in her left calf. The nursing assessment reveals the following: left calf 17.5", right calf 14", left thigh 32", right thigh 28", and a shiny, warm, and reddened left leg. Which of the following interventions should be given priority in the patient's plan of care? i. Maintain bedrest ii. Encourage ambulation TID iii. Apply bilateral antiembolism v. Apply right antiembolism stockings stockings vi. Apply warm moist heat as ordered iv. Encourage bilateral leg exercises
Correct Answer: A
Rationale: The patient's symptoms and assessment findings suggest the presence of deep vein thrombosis (DVT), which is a potential complication following surgery such as a hysterectomy. The priority interventions in this case should focus on preventing the progression of DVT and reducing the risk of pulmonary embolism.