A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

Promote independence in activities of daily living for the client.

Provide relief from pain and discomfort for the client.

Maintain immobilization and alignment for the client.

Provide optimal nutrition and hydration for the client.

Answer and Explanation

The Correct Answer is C

When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly and can prevent complications such as malunion or nonunion.

Promoting independence in activities of daily living for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

Providing relief from pain and discomfort for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

Providing optimal nutrition and hydration for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

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Correct Answer is C

Explanation

When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip ﬂexion of the aﬀected extremity. This can help prevent dislocation of the new hip joint and promote healing.

Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.

Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.

Instructing the client to avoid movement of the aﬀected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the aﬀected leg as part of their rehabilitation and recovery.

A. Nuchal rigidity B. Batle's sign C. Polyuria D. Lethargy

Correct Answer is D

Explanation

The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal ﬂuid². Lethargy (feeling less alert than usual) is a common symptom of increased ICP⁴.

Nuchal rigidity is not a common symptom of increased ICP.

Batle's sign is not a common symptom of increased ICP.

Polyuria is not a common symptom of increased ICP.

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A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

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A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

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