Which of the following actions should be taken by the nurse?
The nurse cares for a child who is in Buck’s traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg.
A. Record the observation. B. Encourage the child to move the foot. C. Cover the colder foot with a sock. D. Notify the physician.
D is the answer to this question. If the question would be analyzed, it will be obvious that there are not enough details that are provided for the nurse to assess what is wrong with the patient’s leg. It only says that the leg is warmer which can be an indication of almost anything.
Since this may seem unusual, this is something that the physician should know so that the proper treatments and actions can be done. There is a possibility that the warmer leg is actually desired in order to improve the healing of the leg. Once again, there is not enough information about this to know for sure.
The answer choices need clarification. choice 2 has no specific foot noted and in my opinion the question can be saying that the uninjured leg is warmer due to a clot since it is warmer than the injured leg. There needs to be clarification on what warmer means, whether that is that the injured leg is cooler than previously assessed or that the uninjured leg is warmer than previously assessed.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) ignores possibility that Ace bandage is too tight
(2) does not relieve the circulation problem
(3) does not relieve the circulation problem
(4) correctassessment indicates that Ace bandage is too tight and needs readjusting