A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics. the client states the pain is unrelieved. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. The nurse suspects compartment syndrome. What is the nurse's most appropriate action?
Promptly inform the primary provider.
Reassess the client's neurovascular status in 15 minutes.
Warm the client's foot and determine whether circulation improves.
Reposition the client with the affected foot dependent.
The Correct Answer is A
Explanation:
A. Promptly inform the primary provider:
Explanation: Compartment syndrome is a medical emergency that requires immediate intervention. If a nurse suspects compartment syndrome due to symptoms like severe unrelieved pain, absent pulses, and pale extremities, the most appropriate action is to promptly inform the primary healthcare provider. The provider can assess the situation, order necessary diagnostic tests, and potentially arrange for emergent interventions like fasciotomy to relieve compartment pressure.
B. Reassess the client's neurovascular status in 15 minutes:
Explanation: Waiting for 15 minutes to reassess the client's neurovascular status is not appropriate in this situation. Compartment syndrome can progress rapidly, leading to irreversible tissue damage within a short time frame. Delaying assessment and intervention can result in significant complications.
C. Warm the client's foot and determine whether circulation improves:
Explanation: Warming the foot is not appropriate in this context. Compartment syndrome is caused by increased pressure within the muscle compartment, leading to compromised circulation. Warming the foot will not address the underlying issue of elevated compartment pressure and can potentially worsen the condition by dilating blood vessels and increasing pressure further.
D. Reposition the client with the affected foot dependent:
Explanation: Repositioning the client with the affected foot dependent is contraindicated in compartment syndrome. Elevating the limb can worsen the condition by further restricting blood flow. The limb should be kept at or slightly below the level of the heart to maintain adequate perfusion until medical intervention can be initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["500"]
Explanation
To calculate the infusion rate in ml/hr for a 500 ml bolus to be administered over 1 hour, you can simply set the pump to deliver the entire volume in the specified time:
500 ml / 1 hour = 500 ml/hr
So, the pump should be set at 500 ml/hr to administer the 500 ml bolus over 1 hour.
Correct Answer is ["84.1"]
Explanation
Weightinkg=185÷2.2≈84.1
Calculate the dose of enoxaparin:
The prescribed dose is 1 mg/kg.
Doseinmg=Weightinkg×Doseperkg
Doseinmg=84.1×1≈84.1
The nurse should administer 84.1 mg of enoxaparin.
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