# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394047&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## 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?

## Option

1. Assess distal pulses, movement, sensation, and notify the provider. **✔ Correct answer**
2. Apply a warm pack over the casted area to improve circulation.
3. Offer relaxation breathing and document expected postoperative pain.
4. Reposition the leg below heart level and reassess at the next round.

**Correct answer: 1**

## Explanation

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.

## In-depth explanation

Clinical Judgment
New severe pain plus impaired perfusion after fracture repair is limb-threatening until proven otherwise.

Memory Tip
Pain out of proportion plus pale/cool equals neurovascular check now.

## Clinical scenario

Clinical Practice Guide
Postoperative extremity assessment includes pain, pulses, color, temperature, capillary refill, movement, and sensation.

Caution
Do not dismiss severe unrelieved pain as routine surgical discomfort.

## Key concepts

- **Neurovascular Assessment** — Assessment of circulation, movement, and sensation in an extremity.
- **Compartment Syndrome** — Increased pressure within a closed muscle compartment that can impair perfusion.
- **Capillary Refill** — A bedside measure of peripheral perfusion after blanching the nail bed or skin.

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