Practice Question
The nurse performs a neurovascular assessment on a client who is immobile because of a fracture to the right lower extremity when the client says, "I know it's my right leg that is broken, but my left heel sure feels uncomfortable." What is the priority action by the nurse?
Answer Choices:
Correct Answer:
Perform an assessment of the client's unaffected extremity.
Rationale:
🔷Assess the unaffected extremity (C) when new heel discomfort is reported: In an immobile client, unexpected contralateral heel pain can signal pressure injury, ischemia, or nerve entrapment; assessment precedes intervention.
🔷Perform a focused exam for color, temperature, capillary refill, pulses, sensation, and skin integrity on the left heel.
🔷Early detection allows you to offload, reposition, and escalate before breakdown occurs.
🔷Continuing with the original limb alone risks missing a preventable injury on the other side.
🔷This approach follows the neurovascular and skin assessment standards for at-risk, immobile patients.
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This question is from W7 NR226 CJE Fundamentals Benchmark 2551 which contains 28 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Fundamentals
- Answer Choices: 4