After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry;
and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
a.
Document the findings and monitor as prescribed.
b.
Increase the frequency of monitoring the client.
c.
Notify the surgeon or anesthesia provider immediately.
d.
Palpate the client's bladder or perform a bladder scan.
ANS: C
With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.
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