Difficulty: Medium
Average Score: 68%
Full-length
Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:
Correct answer
C
Rationale
Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. The extremity will be elevated if ordered by the doctor. Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring. Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action.