Home » NCLEX » NCLEX-RN » 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:
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:
A. Assess vital signs
B. Elevate the extremity
C. Perform a lower extremity neurovascular check
D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use
Correct Answer: C
Explanation/Reference:
Explanation:
(A) 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. (B) The extremity will be elevated if ordered by the doctor. (C) Assessment of the postoperative area is important to determine if bleeding, swelling, or decreased circulation is occurring. (D) Reinforcement of teaching on use of the client-controlled analgesic pump is important, but not the first action.
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