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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse is caring for a client who had a fiberglass cast applied to the right lower leg earlier in the day. The client reports severe, throbbing pain in the right leg that is rated as a 9 on a 0-to-10 scale, despite receiving an oral opioid analgesic one hour ago. The nurse notes that the client's right toes are cool to the touch and capillary refill is 4 seconds. Which action should the nurse take next?

  1. A
    Elevate the casted extremity on pillows above heart level to decrease swelling
  2. B
    Loosen the fiberglass cast using a cast saw to relieve the pressure on the leg
  3. C
    Administer a PRN dose of the prescribed breakthrough pain medication
  4. Communicate the neurovascular findings to the supervising registered nurse right awayAnswer

Answer

The priority action is to immediately communicate the neurovascular findings to the supervising registered nurse or healthcare provider.
The client is exhibiting classic signs of compartment syndrome, which include unrelieved severe pain, cool extremities, and delayed capillary refill. This is a surgical emergency requiring immediate escalation to the registered nurse or healthcare provider to prevent permanent tissue damage and limb loss.

Step-by-Step Solution

1
Analyze the client's symptoms and physical assessment findings.
The client has severe, unrelenting pain, cool toes, and delayed capillary refill greater than 3 seconds following cast application.
These are cardinal signs of compromised circulation and impending compartment syndrome, which is a medical emergency.
2
Determine the appropriate scope of practice and priority intervention.
The immediate priority is escalating the critical findings to the registered nurse or provider for urgent intervention.
Practical nurses must recognize limb-threatening complications and promptly report them; independently altering the cast or inappropriately positioning the limb violates safety standards.

Key Concept

Recognizing and Escalating Compartment Syndrome
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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