An emergency department nurse cares for a client who sustained a ...

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An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first?
 
  a. Assess the pedal pulses.
  b. Apply oxygen by nasal cannula. c.
  Increase the IV flow rate.
  d. Loosen the traction.

Question 2

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?
 
  a. Blood pressure increases to 130/86 mm Hg
  b. Traction weights are resting on the floor
  c. Oozing of clear fluid is noted at the pin site
  d. Capillary refill is less than 3 seconds

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Answer to Question 1

ANS: A
These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.

Answer to Question 2

ANS: B
The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.