Following a motor vehicle accident, a patient arrives in the emergency department with massive swelling of the right lower leg. Which action should the nurse take first?
AElevate the leg on pillows.
BApply a compression bandage.
CPlace ice packs on the lower leg.
DCheck leg pulses and sensation.
Explanations
A
Incorrect
Elevation may help reduce swelling, but the nurse must first assess circulation and nerve function in the injured extremity.
B
Incorrect
Compression can reduce swelling but should not be applied until circulation is assessed, as it could worsen impaired blood flow.
C
Incorrect
Ice may help control swelling, but vascular and neurologic status must be assessed first to detect possible complications.
D
Correct
Massive swelling after trauma may indicate vascular compromise or compartment syndrome, so the priority is to assess distal pulses, circulation, and sensation.
Study Notes
The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injuries such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.