A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Log roll the client and place adult disposable briefs beneath the client.

Maintain traction while the client uses a urinal.

Release the traction so the client can use a bedpan.

Insert an indwelling urinary catheter preoperatively.

Answer and Explanation

The Correct Answer is B

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

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Correct Answer is C

Explanation

Choice A reason: An apical heart rate of 100 to 110 beats/minute is not unusual after surgery, as the client may be experiencing stress, pain, or anxiety. This finding does not require immediate action by the nurse, but should be monitored and reported if it persists or worsens.

Choice B reason: Redness and edema at the incision site are expected signs of inflammation and healing after surgery. This finding does not require immediate action by the nurse, but should be assessed for signs of infection, such as pus, warmth, or foul odor.

Choice C reason: A high-pitched sound heard upon inspiration, also known as stridor, is a sign of upper airway obstruction, which can be life-threatening. This finding requires immediate action by the nurse, such as administering oxygen, suctioning, or calling for help.

Choice D reason: A pain rating of 8 on a scale of 1 to 10 indicates severe pain, which can affect the client's recovery and comfort. This finding requires prompt action by the nurse, such as administering analgesics, repositioning, or providing non-pharmacological interventions. However, this is not as urgent as choice C, which involves the client's airway.

A. Insert a nasogastric tube (NGT) and attach to low intermittent suction. B. Give a prescribed analgesic for temperature above 101°F (38.3° C). C. Place an indwelling urinary catheter and attach a bedside drainage unit. D. Send the client to x-ray for a flat plate of the abdomen.

Correct Answer is A

Explanation

Choice A reason: Inserting a nasogastric tube (NGT) and attaching to low intermittent suction is the priority intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. This can help decompress the stomach, remove gastric contents, prevent further bleeding, and relieve the symptoms. The NGT should be inserted carefully and checked for proper placement before suctioning.

Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3° C) is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Temperature elevation can indicate infection or inflammation, which can be treated with antibiotics or anti-inflammatory drugs. However, analgesics can have adverse effects on the gastrointestinal tract, such as irritation, ulceration, or bleeding. Analgesics should be given cautiously and after the cause of the fever is identified.

Choice C reason: Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Urinary catheterization can help monitor the fluid balance, renal function, and blood loss of the client, but it is not a priority in this situation. Urinary catheterization can also pose risks of infection, trauma, or obstruction, and should be avoided unless necessary.

Choice D reason: Sending the client to x-ray for a flat plate of the abdomen is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. X-ray can help diagnose the location and extent of the ulcer, perforation, or obstruction, but it is not a priority in this situation. X-ray can also expose the client to radiation, which can be harmful, and should be done only after the client is stabilized.

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A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

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