Question

A nurse is acaring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

A. Temperature of 38.2°C (100.8°F)
B. Drainage from the incision that is purulent and red
C. Pain that is controlled with medication
D. Decreased sensation in the toes of the right foot

Answer 1

The nurse should report the finding of decreased sensation in the toes of the right foot to the provider as it may indicate serious complications such as nerve damage or impaired circulation.

Step-by-step explanation:

The assessment finding that the nurse should report to the provider for a patient who is 4 hours postoperative following an open reduction internal fixation of the right ankle is decreased sensation in the toes of the right foot. This decrease in sensation could indicate nerve damage or impaired circulation, which are both serious complications that need immediate attention. In contrast, a temperature of 38.2°C (100.8°F) is a mild fever that might be expected postoperatively and is often managed with medication and close monitoring. Pain that is controlled with medication is not generally a concern, as it indicates that the pain management plan is effective. Finally, even though drainage that is purulent and red could suggest infection, it is less urgent than a loss of sensation, but should still be monitored closely and managed according to the wound care plan in place.