A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first?
1. notify the physician about these findings
2. elevate the leg above the level of the heart
3. wrap the extremity in a loose, warm blanket and apply a foot cradle
4. perform passive range of motion (PROM) exercises to stimulate circulation
Correct Answer: 3
The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, then notify the physician. Elevating the leg above the heart could worsen the ischemia. Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia.
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