# A nurse is caring for a client who sustained a fractured tibia and fibula in a motor vehicle accident 6 hours ago. The client has a long leg cast applied and reports severe pain (8/10) that is not relieved by prescribed analgesics. Which nursing intervention should the nurse implement first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540986  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client who sustained a fractured tibia and fibula in a motor vehicle accident 6 hours ago. The client has a long leg cast applied and reports severe pain (8/10) that is not relieved by prescribed analgesics. Which nursing intervention should the nurse implement first?

The nurse notices the client's toes are pale, cool to touch, and the client reports numbness and tingling in the affected extremity.

## 보기

1. Administer additional pain medication as ordered
2. Elevate the affected extremity above heart level
3. Apply ice packs to the cast to reduce swelling
4. Notify the healthcare provider immediately **✔ 정답**

**정답: 4**

## 해설

Immediate notification of the healthcare provider is required due to signs of compartment syndrome (pale, cool toes with numbness/tingling). This is a surgical emergency to prevent permanent damage.

## 심화 해설

Clinical Reasoning and Priority Setting

The client presents with classic early indicators of acute compartment syndrome (ACS) following a tibial fracture and long leg cast application. The hallmark signs are severe pain unrelieved by analgesics, often described as pain out of proportion to the injury, along with the "5 P's": pain, pallor (pale toes), paresthesia (numbness and tingling), poikilothermia (cool to touch), and paralysis (a late sign) [3]. The pathophysiological basis is increased pressure within a closed osteofascial space, which compromises capillary perfusion and leads to tissue ischemia. If unrelieved, this progresses to irreversible muscle and nerve necrosis within 6 to 8 hours, potentially resulting in limb loss, rhabdomyolysis, renal failure, or even death [3].

In this scenario, the nurse has already identified critical assessment findings that indicate a limb-threatening emergency. The first and most appropriate nursing intervention is to notify the healthcare provider immediately. The definitive treatment for ACS is urgent surgical fasciotomy to decompress the involved compartments [3]. Any delay in diagnosis or management directly increases the risk of long-term morbidity and carries significant medicolegal consequences [3].

The other options are incorrect because they delay definitive care or can worsen the condition:

- Administering additional pain medication (Option 1) is inappropriate because unrelieved pain is a diagnostic clue for ischemia, not simply a need for more analgesia. Masking this symptom without addressing the underlying cause can delay the diagnosis [3,4].

- Elevating the extremity above heart level (Option 2) is contraindicated in suspected compartment syndrome. Elevation reduces arterial perfusion pressure, further compromising blood flow to an already ischemic limb.

- Applying ice (Option 3) can cause vasoconstriction, which further reduces perfusion to the affected tissues and should be avoided.

The importance of early recognition by nurses cannot be overstated. Studies show that nurses in orthopedic and emergency settings play a critical role in the initial identification of ACS, and structured assessment tools like the observational chart for traumatic limb swelling (OCTLS) are being developed to enhance diagnostic accuracy [1,2]. However, in patients with communication barriers, such as those with autism spectrum disorder, the classic symptom of disproportionate pain may be masked or distorted, making vigilant physical assessment of the "P's" even more crucial . The nurse's immediate action of reporting these objective findings ensures the patient receives the timely surgical intervention required to save the limb.

References (research sources)

- [3]Acute Compartment Syndrome: A Short Narrative Review of the Risk Factors, Complications, and Medicolegal Impact of a Missed Diagnosis.Research articleAl-Habsi R. (2025) · DOI: 10.7759/cureus.97781

## 임상 시나리오

Acute Compartment Syndrome: Emergency ResponseRecognizing a Limb-Threatening Emergency After Casting
The earliest and most reliable indicator of acute compartment syndrome is pain out of proportion to the injury, unrelieved by analgesics. This is often accompanied by the 5 P's: Pain, Pallor, Paresthesia, Poikilothermia, and Paralysis (a late sign).

Immediate intervention is provider notification. Definitive treatment is urgent fasciotomy to decompress the compartment. Tissue ischemia can become irreversible within 6 to 8 hours, leading to necrosis, limb loss, or rhabdomyolysis.

CautionDo **not** elevate the limb above heart level as this reduces arterial perfusion. Do **not** apply ice, which causes vasoconstriction. Do **not** give additional analgesics that mask ischemic pain and delay diagnosis.

## 핵심 개념

- **Acute Compartment Syndrome** — A condition where increased pressure within a closed osteofascial space compromises capillary perfusion, leading to tissue ischemia and potentially irreversible necrosis within 6-8 hours.
- **5 P's of Compartment Syndrome** — Classic assessment findings: Pain (out of proportion, unrelieved by analgesia), Pallor, Paresthesia, Poikilothermia (coolness), and Paralysis (late sign).
- **Fasciotomy** — The definitive surgical treatment for compartment syndrome, involving an incision through the fascia to relieve pressure and restore tissue perfusion.
- **Neurovascular Assessment** — Systematic evaluation of an extremity including color, temperature, capillary refill, sensation, motor function, and pain level to detect vascular or nerve compromise.

## 같은 주제 문제

- [A 45-year-old construction worker is brought to the emergency department after falling fro…](https://mymerci.kr/pages/nclex_q.php?qn_id=540984)
- [A 45-year-old construction worker is brought to the emergency department after falling fro…](https://mymerci.kr/pages/nclex_q.php?qn_id=540985)
- [A nurse is caring for a client who sustained a closed fracture of the right tibia 6 hours …](https://mymerci.kr/pages/nclex_q.php?qn_id=540987)
- [A 28-year-old athlete is admitted to the emergency department after a skiing accident, wit…](https://mymerci.kr/pages/nclex_q.php?qn_id=540988)
- [A 65-year-old woman is brought to the emergency department after slipping on ice and landi…](https://mymerci.kr/pages/nclex_q.php?qn_id=540989)
- [A nurse is caring for a client who sustained a compound fracture of the tibia 6 hours ago.…](https://mymerci.kr/pages/nclex_q.php?qn_id=540990)
- [A 72-year-old woman is brought to the emergency department after a fall at home, landing o…](https://mymerci.kr/pages/nclex_q.php?qn_id=540991)
- [A 45-year-old construction worker is brought to the emergency department after falling fro…](https://mymerci.kr/pages/nclex_q.php?qn_id=540992)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._