Four hours after open reduction and internal fixation of a fractured tibia, a client reports increasing pain t…

Question

Four hours after open reduction and internal fixation of a fractured tibia, a client reports increasing pain that is not relieved by prescribed opioid medication. The toes are pale and cool. Which action should the nurse take first?

Accepted Answer

Option 1: Assess distal pulses, movement, sensation, and notify the provider.

Increasing pain unrelieved by opioids with pale, cool toes suggests possible neurovascular compromise or compartment syndrome. The nurse should immediately assess circulation, movement, and sensation and notify the provider. Delaying care or applying heat can worsen tissue injury.

Answer

Option 2: Apply a warm pack over the casted area to improve circulation.

Answer

Option 3: Offer relaxation breathing and document expected postoperative pain.

Answer

Option 4: Reposition the leg below heart level and reassess at the next round.

Four hours after open reduction and internal fixation of a fractured tibia, a client reports increasing pain that is not relieved by prescribed opioid medication. The toes are pale and cool. Which action should the nurse take first?

In-depth explanation

Clinical scenario

Key concepts

Master the NCLEX-RN with MyMerci

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Four hours after open reduction and internal fixation of a fractured tibia, a client reports increasing pain that is not relieved by prescribed opioid medication. The toes are pale and cool. Which action should the nurse take first?

In-depth explanation

Clinical scenario

Key concepts

Master the NCLEX-RN with MyMerci