A patient has a suspected lower-leg fracture after a fall. The foot is pale and cool, and the dorsalis pedis pulse is absent. Which action should the nurse take first?
Correct answer: C. Report the absent pulse immediately and maintain immobilisation
- A. Apply a warm pack to the affected foot
- B. Document the finding and reassess after one hour
- C. Report the absent pulse immediately and maintain immobilisation
- D. Encourage active ankle exercises to improve circulation
Explanation
An absent distal pulse with a pale, cool foot suggests impaired circulation and possible vascular compromise. Circulation is assessed and protected before comfort measures or exercises, so the finding requires immediate reporting while the limb remains immobilised. Heat and active movement may worsen tissue injury.
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About Skeletal and Muscular Systems
The skeletal and muscular systems include bone structure, joints, cartilage, the axial and appendicular skeleton, and the roles of ligaments and tendons. They also cover skeletal muscle organization, the sliding filament mechanism, neuromuscular contraction, and common differences between voluntary skeletal muscle, cardiac muscle and smooth muscle.
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