Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

Choice A reason: Bathing the wound daily with soap and water is a common practice to maintain cleanliness and prevent infection in a wound. However, this is not the immediate priority in this scenario. The presence of a dusky color on the left foot indicates potential vascular compromise, which needs to be assessed first to ensure adequate blood flow to the affected area. Cleaning the wound can be done subsequently, but checking circulation is critical to address any immediate risks.
Choice B reason: Recording the color and temperature of the leg is an important assessment step to monitor the client's condition. These observations can provide valuable information about the client's peripheral circulation and skin condition. However, while this should be done as part of the overall assessment, it is not the most immediate action. Checking the pulses will give more direct information about the blood supply to the affected area, which is crucial for identifying any urgent circulatory issues.
Choice C reason: Performing dorsiflexion and extension exercises can help maintain joint mobility and muscle strength in clients with diabetes. However, it is not the first intervention that should be implemented in this scenario. Before recommending exercises, it is essential to assess the vascular status of the client's foot. Exercises may not be appropriate if there is significant circulatory compromise, and could potentially cause further harm.
Choice D reason: Checking the client's dorsalis pedis and posterior tibialis pulse points is the most critical first intervention. The dusky color of the foot suggests a possible issue with blood flow. By assessing the pulses in the foot, the practical nurse can determine if there is adequate perfusion to the area. If the pulses are weak or absent, it may indicate peripheral artery disease or another vascular issue that requires immediate medical attention. Prompt identification and intervention are crucial to prevent further complications, such as tissue necrosis or limb-threatening ischemia.

Choice A reason: Fat emboli, or fat embolism syndrome (FES), is the most critical complication to monitor for in a client who had a long bone fracture repaired. This condition occurs when fat droplets from the bone marrow enter the bloodstream and travel to the lungs, brain, or other organs. Symptoms can include respiratory distress, confusion, and a petechial rash. FES can develop within 24 to 72 hours after the injury or surgery and can be life-threatening. Therefore, it is essential to observe for signs such as sudden shortness of breath, rapid breathing, changes in mental status, and the characteristic rash. Early detection and intervention are crucial to manage this potentially severe complication.
Choice B reason: Urinary retention is a possible postoperative complication due to anesthesia or immobility. It is important to monitor urine output and ensure that the client is voiding adequately. However, it is not as immediately life-threatening as a fat embolism. While urinary retention requires attention and management, the practical nurse should prioritize monitoring for signs of fat embolism due to its more severe and acute nature.
Choice C reason: Nonunion refers to the failure of the fracture to heal properly, which can lead to chronic pain and functional impairment. This complication typically develops over a more extended period rather than immediately postoperatively. Monitoring for signs of nonunion, such as persistent pain and lack of healing on follow-up X-rays, is important. However, it is not the most urgent concern in the immediate postoperative period when compared to the risk of a fat embolism.
Choice D reason: Muscular spasms can occur after a fracture as the muscles around the injury site contract to protect and stabilize the affected area. These spasms can be painful and impact the client's comfort and mobility. While it is necessary to address muscle spasms through pain management and physical therapy, they are generally not life-threatening. The practical nurse should focus on monitoring for signs of fat embolism, which poses a more immediate risk to the client's health.