Clinical Scenario:

A nurse is assessing a patient who had an external fixation device placed for a tibial fracture 8 hours ago. The patient reports increasing pain that is not relieved by prescribed pain medications. Upon assessment, the nurse notes swelling, a pale and cool foot, and diminished sensation in the toes.

Which of the following assessments should the nurse perform next to further evaluate for compartment syndrome?

Assess for the presence of pedal pulses and capillary refill time.

Measure the patient's calf circumference and compare it bilaterally.

Ask the patient to flex and extend the affected foot to assess for range of motion.

Check for redness and drainage at the pin sites of the external fixation device.

Answer and Explanation

The Correct Answer is A

A. Assess for the presence of pedal pulses and capillary refill time: Compartment syndrome can lead to diminished or absent pulses, delayed capillary refill, and decreased circulation. Assessing pedal pulses and capillary refill is a crucial step in confirming the diagnosis.

B. Measure the patient’s calf circumference and compare it bilaterally: Measuring limb circumference can help assess swelling, but it is not the most critical assessment in this situation. Capillary refill and pedal pulses provide more immediate information about circulation.

C. Ask the patient to flex and extend the affected foot to assess for range of motion: Limited movement can be a sign of compartment syndrome, but if severe pain is already present, further movement may cause more damage. Assessing circulation should be prioritized first.

D. Check for redness and drainage at the pin sites of the external fixation device: Redness and drainage may indicate infection, but this does not directly assess for compartment syndrome. Circulatory assessment is more urgent.

Nursing Test Bank

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Correct Answer is B

Explanation

A. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.

B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.

C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.

D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.

A. The surgical dressing has a small amount of serosanguinous drainage. B. The patient's hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb.

Correct Answer is D

Explanation

A. The surgical dressing has a small amount of serosanguinous drainage. Light serosanguinous drainage is expected postoperatively and does not require immediate intervention.
B. The patient’s hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. A mild drop in hemoglobin postoperatively is expected due to blood loss during surgery. This does not require immediate intervention.
C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. Mild discomfort is expected and can be managed with prescribed analgesics.
D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb. These findings indicate impaired circulation or vascular compromise, which could suggest compartment syndrome or arterial occlusion. Immediate intervention is required to prevent limb ischemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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