The nurse is providing care for a patient following an open reduction surgery of a fracture. Which finding should the nurse report immediately to the HCP?

There is numbness and tingling sensations in the surgical limb.

Surgical pain is a 4 on a scale 0-10.

The foot on the surgical limb is slightly cooler that the other limb.

There are +2 pulses and the surgical limb is pink in color.

Answer and Explanation

The Correct Answer is A

A. There is numbness and tingling sensations in the surgical limb. Numbness and tingling may indicate neurovascular compromise, such as compartment syndrome or nerve damage, requiring immediate medical attention.

B. Surgical pain is a 4 on a scale 0-10. Pain at a level 4 postoperatively is generally manageable and expected. It does not indicate an immediate complication.

C. The foot on the surgical limb is slightly cooler than the other limb. While a slightly cooler foot could be a concern, it is less urgent than numbness and tingling. Monitoring and comparing with other symptoms are necessary.

D. There are +2 pulses and the surgical limb is pink in color. This indicates good circulation and is a positive sign, not requiring immediate reporting.

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Correct Answer is A

Explanation

A. Toes cold to touch: Cold toes can indicate compromised circulation, potentially due to compartment syndrome or other vascular issues, and should be reported immediately.

B. Pink tissue around the pin sites: Pink tissue around the pin sites usually indicates normal healing and is not generally a cause for concern unless accompanied by other symptoms of infection or inflammation.

C. Blanching of the toenail beds with pressure: Blanching of the toenail beds with pressure is a normal finding in assessing capillary refill and does not typically indicate a serious issue on its own.

D. Serous drainage from the pin sites: Serous drainage (clear, yellowish fluid) is common and expected post-operatively and does not usually indicate an infection or other complication unless there are additional concerning symptoms.

A. Explain the use of assistive devices. B. Clean skin with antibacterial skin cleaning cloths. C. Teach postoperative exercises. D. Ask if a consent form was signed.

Correct Answer is B

Explanation

A. Explain the use of assistive devices. While explaining the use of assistive devices is important, it is not the primary preoperative care focus.

B. Clean skin with antibacterial skin cleaning cloths. Correct. Preoperative skin cleaning with antibacterial cloths is crucial to reduce the risk of postoperative infections.

C. Teach postoperative exercises. Teaching postoperative exercises is important but is typically part of preoperative education rather than immediate preoperative care.

D. Ask if a consent form was signed. Ensuring that consent forms are signed is necessary but is not the primary preoperative care focus.

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