A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

Choice A reason:

Palpating the dorsalis pedis pulse is the appropriate option. Checking the dorsalis pedis pulse is crucial to assess the perfusion and circulation to the affected extremity. This is an important nursing action to monitor the patient's vascular status and ensure that there is adequate blood flow to the extremity distal to the fixator. A decrease or absence of the dorsalis pedis pulse could indicate potential circulation issues and require immediate attention.

Choice B reason:

Adjusting the clamps on the fixator frame is incorrect. The nurse should not adjust the clamps without specific orders from the healthcare provider. The external fixator is typically secured according to the surgeon's specifications, and any adjustments should be made under the guidance of the surgical team.

Choice C reason:

Wrapping sterile gauze on the sharp point of the pins is incorrect. The sharp pins used in an external fixator are an integral part of the device and are placed to stabilize the fracture. They should not be covered with sterile gauze, as this could interfere with their function and increase the risk of infection.

Choice D reason:

Maintaining the affected extremity in a dependent position is incorrect. Keeping the affected extremity in a dependent position (lower than the heart) can increase swelling and impair circulation. After surgery and fixation, it's often recommended to elevate the extremity to reduce swelling and promote proper circulation.

Choice Areason:

Placing pillows under the client's knees might be useful for comfort, but it doesn't directly address the risk of DVT.

Choice Breason:

Discouraging leg exercises while in bed is not recommended because it can lead to decreased circulation and an increased risk of blood clot formation.

Choice C reason:

Applying compression stockings to the lower extremities is recommendable. After an open cholecystectomy surgery, the client is at risk for developing deep vein thrombosis (DVT) due to reduced mobility and surgical trauma. Applying compression stockings to the lower extremities can help improve blood circulation and reduce the risk of blood clot formation.

Choice D reason:

Avoiding the use of anticoagulants is not recommendable, if prescribed by the healthcare provider, could be detrimental in preventing postoperative complications like DVT. Anticoagulants are often used to prevent clot formation in high-risk surgical patients.