The nurse admits a client from the emergency department (ED) with a newly placed leg cast. Which actions should the nurse perform to prevent neurovascular impairment?
1. Assess the toes for nerve and circulatory impairment every hour for 8 hours.
2. Place the leg on pillows.
3. Apply ice to the site.
4. Elevate the foot of the bed.
5. Report excessive swelling or indications of neurovascular impairment.
2, 3, 4, 5
Rationale 1: The toes should be assessed every 30 minutes for 4 hours and then every 3 hours for the first 24–48 hours, when edema is likely to subside somewhat.
Rationale 2: The limb should be elevated.
Rationale 3: Ice should be applied to the site.
Rationale 4: The foot of the bed should be elevated.
Rationale 5: Excessive swelling or neurovascular impairment should be reported.
Global Rationale: The toes should be assessed every 30 minutes for 4 hours and then every 3 hours for the first 24–48 hours, when edema is likely to subside somewhat. The limb should be elevated. Ice should be applied to the site. The foot of the bed should be elevated. Excessive swelling or neurovascular impairment should be reported.
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