A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?

Administer PRN pain medication.

Observe the leg for swelling.

Assess peripheral pulses.

Auscultate blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering PRN pain medication can help manage the client's discomfort, but it does not address the underlying cause of the pain. It is essential to assess and identify the source of the pain before administering pain relief. Providing pain medication without a thorough assessment may mask symptoms of a serious underlying issue.

Choice B reason: Observing the leg for swelling is important, as swelling can indicate complications such as compartment syndrome or infection. However, it is not the first action the nurse should take. While swelling is a significant sign, assessing blood flow to the extremity is more critical and should be prioritized.

Choice C reason: Assessing peripheral pulses is the correct first intervention. The presence of foot pain in a client with an external fixation device for a fractured femur could indicate compromised blood flow to the lower extremity. Assessing the peripheral pulses will help determine if there is adequate circulation. If pulses are weak or absent, it may suggest a serious vascular issue that requires immediate intervention to prevent further complications such as tissue ischemia or necrosis.

Choice D reason: Auscultating blood pressure is a routine assessment but does not directly address the immediate concern of left foot pain in this scenario. Blood pressure assessment is important for overall health monitoring but is not the priority when dealing with a possible vascular complication in the affected limb. Ensuring adequate blood flow to the extremity takes precedence.

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Correct Answer is C

Explanation

Choice A reason: A fasting serum glucose level of 140 mg/dL (7.77 mmol/L) indicates hyperglycemia, which is elevated but not an immediate life-threatening complication. It suggests poor blood glucose control but does not directly indicate a complication specific to type 2 diabetes and hypertension. This value should prompt further evaluation and adjustments in diabetes management, but it is not as critical as other potential findings.

Choice B reason: A glycosylated hemoglobin (A1c) level of 6.9% is within the range of good diabetic control. While it indicates the client has been managing their blood glucose levels relatively well over the past few months, it does not suggest a current complication. This value is used to assess long-term glucose control rather than acute issues.

Choice C reason: A serum creatinine level of 1.6 mg/dL (141.44 umol/L) is elevated and indicates impaired kidney function. Clients with type 2 diabetes mellitus and hypertension are at increased risk for kidney disease, known as diabetic nephropathy or hypertensive nephropathy. Elevated creatinine levels suggest that the kidneys are not filtering waste products effectively, which is a significant complication that requires immediate attention and intervention.

Choice D reason: A white blood cell (WBC) count of 11,000/mm3 (11 x 10^9/L) is slightly elevated and may suggest an infection or inflammation. However, it is not a specific complication related to type 2 diabetes mellitus and hypertension. Elevated WBC counts warrant further investigation to identify any underlying infection or inflammatory process, but it is not as directly related to diabetic or hypertensive complications as elevated serum creatinine.

A. Wrap the feet with warmed blankets. B. Elevate extremities on pillows. C. Assess pulses with a vascular doppler. D. Evaluate edema for pitting.

Correct Answer is C

Explanation

Choice A reason: Wrapping the feet with warmed blankets may provide comfort and warmth, but it does not address the immediate concern of assessing the circulation status in the lower extremities. It is not the first action to take in this situation.

Choice B reason: Elevating the extremities on pillows can help reduce edema and improve circulation, but it should not be the first action taken. Assessing the pulses is crucial to determine the severity of the circulation issue and guide further interventions.

Choice C reason: Assessing pulses with a vascular doppler is the correct first action. Since the pedal pulses are not palpable, using a vascular doppler can help determine if there is any blood flow in the lower extremities. This assessment is essential to identify potential complications such as arterial occlusion or compromised circulation, which require immediate intervention.

Choice D reason: Evaluating edema for pitting can provide information about the extent of the swelling, but it does not address the immediate concern of assessing blood flow. Assessing pulses with a vascular doppler is a more critical first step to ensure the client's circulation status is evaluated accurately.

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A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?

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