A client who ruptured his spleen in a motor vehicle accident rates his

A client who ruptured his spleen in a motor vehicle accident rates his postoperative pain as a level 8 on a 0 to 10 pain scale.

After administering pain medication, the nurse discusses the use of complementary therapies with the client to explore ways to reduce the pain. The client would like to try a massage. The nurse delegates this task to the assistive personnel (AP). Which of the following instructions is most important for the nurse to share with the AP?
1. “You need to warm the bottle of lotion before using it.”
2. “Report any changes in the client’s skin condition to me immediately.”
3. “Do not massage the client’s legs.”
4. “Massage each body part at least 10 minutes.”

ANSWER

ANS: 3
The nurse should instruct the AP not to massage the client’s legs or calf muscles, because there is a risk for dislodging a vascular clot. The nurse needs to know about changes in the condition of the client’s skin, but this can be obtained after the client’s massage—it is not as critical as the AP’s knowing not to massage the client’s legs before beginning the massage.