Clinical Scenario:

A nurse is assessing a patient who had an external fixation device placed for a tibial fracture 8 hours ago. The patient reports increasing pain that is not relieved by prescribed pain medications. Upon assessment, the nurse notes swelling, a pale and cool foot, and diminished sensation in the toes.

Which of the following assessments should the nurse perform next to further evaluate for compartment syndrome?

Assess for the presence of pedal pulses and capillary refill time.

Measure the patient's calf circumference and compare it bilaterally.

Ask the patient to flex and extend the affected foot to assess for range of motion.

Check for redness and drainage at the pin sites of the external fixation device.

Answer and Explanation

The Correct Answer is A

A. Assess for the presence of pedal pulses and capillary refill time: Compartment syndrome can lead to diminished or absent pulses, delayed capillary refill, and decreased circulation. Assessing pedal pulses and capillary refill is a crucial step in confirming the diagnosis.

B. Measure the patient’s calf circumference and compare it bilaterally: Measuring limb circumference can help assess swelling, but it is not the most critical assessment in this situation. Capillary refill and pedal pulses provide more immediate information about circulation.

C. Ask the patient to flex and extend the affected foot to assess for range of motion: Limited movement can be a sign of compartment syndrome, but if severe pain is already present, further movement may cause more damage. Assessing circulation should be prioritized first.

D. Check for redness and drainage at the pin sites of the external fixation device: Redness and drainage may indicate infection, but this does not directly assess for compartment syndrome. Circulatory assessment is more urgent.

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Correct Answer is D

Explanation

A. Medicate the client for pain: Pain management is essential after surgery; however, it is not the most critical action. Unrelieved pain could indicate a complication, such as compartment syndrome, which requires further assessment.

B. Direct the client to perform exercises of the ankle and toes: Performing ankle and toe exercises helps prevent complications such as venous thromboembolism (VTE) and promotes circulation, but it is not the priority over assessing for complications.

C. Instruct the client on the use of crutches: Teaching the client how to use crutches is important for mobility, but this is not the most immediate postoperative concern.

D. Perform neurovascular checks of the extremities: This is the most important intervention because neurovascular compromise (e.g., compartment syndrome) can occur after orthopedic surgery. Checking circulation, movement, and sensation (CMS) is critical for early detection of complications.

A. Moderate level of pain B. Dependent edema distal to the cast C. Itching of the distal foot D. Inability to flex the toes of the casted foot

Correct Answer is D

Explanation

A. Moderate level of pain: Pain is expected after a fracture and casting. However, if pain is severe and unrelieved by medication, it may indicate compartment syndrome, which is an emergency. Moderate pain alone does not require immediate provider notification.

B. Dependent edema distal to the cast: Some swelling is expected due to reduced mobility and gravity-dependent positioning. Elevating the leg can help reduce swelling, but it does not require immediate provider notification.

C. Itching of the distal foot: Itching is a common, non-emergency side effect of casting. Clients should be advised not to insert objects inside the cast to relieve itching.

D. Inability to flex the toes of the casted foot: Inability to flex the toes suggests potential neurovascular compromise or compartment syndrome, a medical emergency requiring immediate intervention to prevent permanent nerve or muscle damage. The provider must be notified immediately.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Correct Answer is D

Explanation

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Correct Answer is D

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