Difficulty: Medium
Average Score: 74%
Simulated
A nurse is caring for a client postoperative closed reduction of the left ankle with a short cast in place. Which assessments of the client's affected leg should the nurse make? (SELECT ALL THAT APPLY)
Correct answer
A,B,C,D,E
Rationale
Capillary refill is a key indicator of circulation to the affected area. It should be assessed to ensure adequate perfusion. Pain assessment is critical for identifying any complications such as compartment syndrome or inadequate pain management. The ability to move the toes helps assess for nerve function and mobility. Posterior tibialis and pedal pulses assess the circulation and can help identify signs of vascular compromise. Skin temperature and color help identify signs of poor circulation, swelling, or potential complications like compartment syndrome.