A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment?

A. Presence of a distal pulse.
B. Pain with a pain rating scale.
C. Vital sign changes.
D. Potential for drug tolerance.

A. Presence of a distal pulse.

Explanation:

A. Presence of a distal pulse.✔

The nurse will need to examine the client's capability to move her toes and the availability of distal pulses, which as to do with a neurovascular examination of the area beneath the cast.

The more the pain unrelieved by the use of analgesics and is observed at 4 to 12 hours from the onset of casting or trauma can be an indication of compartment syndrome, that can results to total damage to nerves and muscles.

B. Pain with a pain rating scale.❌

Even though the nurse can employ a pain rating scale to determine the alteration in vital signs to basically evaluate the client's pain, the client's complaints will infer early and major signs of compartment syndrome that needs immediate intervention.

C. Vital sign changes.❌

This examination might be necessary once the uncertainty of compartment syndrome has been properly judged.

D. Potential for drug tolerance.❌

The nurse should have an understanding of this signs to prevent misinterpretation of these symptoms for drug tolerance.

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Explanation: