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NCLEX-RN · Question #715

Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:

The correct answer is C. Perform a lower extremity neurovascular check. (A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. (B) The extremity will be elevated if ordered by the doctor. (C) Assessment of the postoperative area…

Physiological Integrity: Reduction of Risk Potential

Question

Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:

Options

  • AAssess vital signs
  • BElevate the extremity
  • CPerform a lower extremity neurovascular check
  • DRemind the client that he has a client-controlled analgesic pump, and reinstruct him on its use

How the community answered

(53 responses)
  • A
    11% (6)
  • B
    2% (1)
  • C
    79% (42)
  • D
    8% (4)

Explanation

(A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. (B) The extremity will be elevated if ordered by the doctor. (C) Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring. (D) Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action.

Topics

#neurovascular assessment#postoperative orthopedic#compartment syndrome#priority assessment

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