A charge nurse is explaining the role of a licensed practical nurse to an assistive personnel (AP). Which of the following responsibilities should the charge nurse include?

Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood flow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.

Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood flow due to increased pressure within the compartment.

Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,

which can be a sign of compartment syndrome.

Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inflammation or infection.

Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.

Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.

By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.

d. Remove the IV catheter.

Explanation:

The correct answer is d. Remove the IV catheter.

If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.

Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.

Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.

Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.

By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.