Question

Your client has an external fixator to the right lower extremity to stabilize an open fracture of the tibia and fibia with extensive soft tissue damage. The client is complaining of a tingling sensation in the foot. Which is the priority nursing action in response to the client's new complaint? A. Administer pain medication B. Assess pain level using a pain scale C. Notify physician of client's status D. Perform neurovascular assessment

Short answer

D. Perform neurovascular assessment

Step-by-step solution

Identify the Issue

The client is experiencing a tingling sensation in the foot which could indicate a neurovascular compromise or impending issue related to the external fixation.

Determine the Priority Action

In a situation where there is a potential compromise to the neurovascular status, it is essential to first assess the affected extremity for circulation, sensation, and movement.

Rule Out Options

While administering pain medication may be necessary, it is not the immediate priority without further assessment. Notifying the physician is an action to be taken after an assessment has been completed if the findings are abnormal.

Select the Best Action

Perform a neurovascular assessment to evaluate for any signs of compromised blood flow or nerve function, which may require immediate intervention.

Key concepts

NCLEX-RN Examination

The NCLEX-RN examination is a standardized test that determines whether a candidate is prepared for entry-level nursing practice. For nursing students, mastering the type of questions found on the NCLEX, especially regarding patient care and priority actions, is crucial. Tingling in the extremity of a patient with an external fixator, such as in the provided scenario, is a situation that may appear on the exam. Candidates must be able to assess and identify the correct priority nursing action, which is a critical thinking skill the NCLEX aims to measure.

When answering such questions, it's essential to use a systematic approach, just as nurses would in real-life situations. Understanding the rationale behind each action can help students prioritize patient needs effectively, a key competency evaluated by the exam.

External Fixator

An external fixator is a surgical treatment used to stabilize fractures by attaching pins or screws to the affected bone from outside the body. This device is often employed in cases of complex fractures like those involving the tibia and fibula with extensive tissue damage. It's essential for nurses to understand how an external fixator functions in order to monitor for complications, such as infection at pin sites or neurovascular compromise.

Proper care, including regular assessment of the affected extremity, is paramount to ensure healing and avoid further injury. Monitoring sensation changes, like the tingling sensation mentioned in the exercise, is part of the nursing responsibilities to quickly identify potential issues.

Tibia and Fibula Fracture

A fracture to the tibia and fibula, the bones of the lower leg, can be severe, particularly when it's an open fracture with extensive soft tissue damage. Such injuries can compromise the stability of the lower extremity and affect neurovascular function. Nursing care for such fractures goes beyond pain management and includes diligent monitoring of neurovascular status and immobilization techniques.

Recognition of signs indicating potential complications, including a change in sensation, is vital for successful healing and preventing further damage. In the educational context, understanding the types of fractures and treatment methods aids in developing a comprehensive nursing approach.

Nursing Priority Action

Identifying nursing priority actions is an essential skill for effective patient care. It involves recognizing the most critical needs of the patient at a given time and responding appropriately. In the scenario provided, the priority action is to perform a neurovascular assessment before considering other interventions such as pain medication or notifying a physician.

This step is essential to ensure that the patient's tingling sensation is not due to a serious complication that could threaten limb viability. It also reflects the nurse's role in patient advocacy, highlighting the need to evaluate for potential neurovascular compromise first.

Neurovascular Compromise

Neurovascular compromise in the context of the lower extremity could indicate impairments in blood flow, sensation, or both, and it is a potential emergency situation that requires immediate nursing attention. A tingling sensation might be an early sign of such a compromise, where prompt assessment and intervention could be limb-saving.

A thorough neurovascular assessment includes checking for the five Ps: Pain, Pallor, Pulselessness, Paresthesias, and Paralysis. Recognizing these early warning signs allows nurses to intervene quickly and appropriately, which could significantly impact the patient's recovery and outcome.