A patient is recovering from a heart transplant surgery and is at risk of blood clots because of his immobility status. The nurse has given the patient a nursing diagnosis of Ineffective Peripheral Tissue Perfusion related to decreased venous blood flow. Which of the following interventions would the nurse utilize with this diagnosis?

 

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Correct

- Measure calf and thigh circumference daily

- Have the patient ambulate at least 5 times per day

- Massage the lower legs to promote circulation

- Administer intravenous potassium supplements as ordered

Rationale

An immobile patient is at risk of deep vein thrombosis (DVT), which develops as a blood clot in a major vein of the pelvis or the lower extremities. If untreated, the clot could break off and travel through the bloodstream to lodge in a small vessel and occlude blood flow, causing a stroke or pulmonary embolism. Because a DVT may develop in a large vein of the calf, the nurse can check for signs of DVT by measuring the calf circumference daily. If a DVT develops, the calf may be enlarged with swelling.

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