NCLEX-RNPhysiological AdaptationHard
A nurse is assessing a client 2 hours after a below-knee cast application. The client reports severe pain unrelieved by opioids, and the toes are pale, cool, and have delayed capillary refill. What is the nurse's priority action?
- AAdminister the next scheduled opioid dose early
- BNotify the healthcare provider immediately
- CElevate the leg above heart level and apply ice
- DReassess in 30 minutes and document findings
Show answer & explanationAnswer & explanation
Correct answer: B. Notify the healthcare provider immediately
These are classic signs of acute compartment syndrome (pain out of proportion to injury unrelieved by opioids, pallor, coolness, delayed capillary refill), a limb-threatening emergency requiring immediate provider notification for possible cast removal or fasciotomy before irreversible tissue damage occurs.
Why the other options are wrong
- A. Pain unrelieved by opioids is a hallmark sign of compartment syndrome, not undertreated pain.
- C. Elevation and ice can further reduce perfusion and worsen compartment syndrome.
- D. Delaying action risks irreversible ischemic damage within hours.
Acute Compartment Syndrome
Increased pressure within a muscle compartment compromises perfusion, causing ischemia; it is a surgical emergency.
- 6 P's: Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia, Paralysis
- Pain out of proportion to injury, unrelieved by opioids, is earliest sign
- Pulselessness is a late finding, do not wait for it
- Requires urgent fasciotomy or cast removal
Memory trick: 6 P's: Pain unrelieved is the first red flag