A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast
The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do?
a.
Notify charge nurse of impending compartment syndrome
b.
Document that all assessments are within normal limits
c.
Inform charge nurse about probable hemorrhage
d.
Place warm compresses on left foot
ANS: B
All of the assessments are within normal limits. A small amount of blood on the cast is expected and should be monitored.
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