Question

A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which nursing assessment is of highest priority?

a. Monitoring for heel breakdown.
b. Monitoring for bladder distention.
c. Monitoring for extremity shortening.
d. Monitoring for loss of blanching ability of toe nail beds.

Answer 1

Postoperative care of a client with an orthopedic leg injury prioritizes monitoring for loss of blanching ability of toenail beds to detect circulatory compromise, which is critical for timely intervention and preserving limb viability.

Step-by-step explanation:

The postoperative care of a client with an orthopedic leg injury requires close and careful monitoring. Among the options provided, monitoring for loss of blanching ability of toenail beds is the highest priority immediately following surgery. This assessment helps to detect any compromise in the circulatory status of the extremity, which can be indicative of serious complications such as compartment syndrome or thrombosis. While all the provided options are important, preserving the viability of the limb is critical, and early identification of circulatory issues allows for timely intervention. Therefore, vascular assessment and ensuring blood flow is not impeded by the cast are crucial for the patient's recovery.

Answer 2

The highest priority nursing assessment postoperatively for a client with a leg injury and cast application is monitoring for loss of blanching ability of toe nail beds.

Step-by-step explanation:

The postoperative nursing assessment of highest priority for a client with an orthopedic leg injury and cast application is monitoring for loss of blanching ability of toe nail beds. This assessment helps identify potential neurovascular compromise, such as compartment syndrome, which can lead to permanent damage if not treated promptly. The nurse should check for any color changes, capillary refill, temperature, and sensation in the toes.