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 B
Explanation
A. Venous thromboembolism (VTE) - While VTE can cause leg pain and swelling, the presence of fever, chills, and localized trauma history in this scenario points more toward cellulitis.
B. Cellulitis
The client's symptoms, including pain, swelling, fever, chills, and sweating, are indicative of cellulitis, which is a bacterial skin infection. The history of trauma to the leg (hitting the leg on the car door) could have introduced bacteria into the skin, leading to the infection. The client's diabetes mellitus type 2 also increases the risk of developing skin infections due to impaired immune function and circulation. Cellulitis often presents with localized pain, swelling, warmth, redness, and systemic symptoms like fever and chills. Immediate medical evaluation and appropriate antibiotic treatment are necessary for cellulitis.
C. Arterial insufficiency - Arterial insufficiency typically presents with symptoms like intermittent claudication, rest pain, and non-healing wounds due to poor circulation. The symptoms described in the scenario are more consistent with an acute infection (cellulitis) rather than chronic arterial insufficiency.
D. Thrombocytopenia - Thrombocytopenia is a condition characterized by low platelet count and does not directly cause localized pain, swelling, and redness in the leg as described in the scenario.
Correct Answer is D
Explanation
A. Increase sodium intake - This is not a preventive measure for osteoporosis. High sodium intake can lead to increased calcium excretion and weaken bones.
B. Drink a cup of coffee each morning - Caffeine consumption, especially in excess, can interfere with calcium absorption and increase calcium excretion. Limiting caffeine intake is recommended for bone health. Drinking coffee in moderation is acceptable but excessive consumption should be avoided.
C. Have a bone-density scan each year - While bone-density scans (DEXA scans) are useful for diagnosing osteoporosis or assessing bone health, they are not typically recommended for young adults with a family history of osteoporosis unless there are specific risk factors present. Yearly scans are unnecessary and not cost-effective for young adults without significant risk factors.
D. Engage in weight-bearing exercise regularly - Weight-bearing exercises, such as walking, jogging, dancing, and resistance training, help to increase bone density and strength. Regular physical activity, especially weight-bearing exercises, is a recommended preventive measure against osteoporosis.
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