A patient with a lower-leg cast reports worsening pain despite prescribed analgesia. The toes are pale, cool, and difficult to move. What should the nurse do first?
Correct answer: B. Assess circulation, sensation, and movement and escalate urgently
- A. Elevate the limb and review it during the next round
- B. Assess circulation, sensation, and movement and escalate urgently
- C. Apply a warm pack over the cast for comfort
- D. Encourage active toe exercises against resistance
Explanation
Pain that is worsening with pallor, coolness, and impaired movement may indicate neurovascular compromise. Immediate neurovascular assessment and urgent escalation are required to prevent permanent tissue damage.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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