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 A

Explanation

The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.

Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, assisting the client back into bed, and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.

A. Place a trochanter roll against the thigh. B. Place a sandbag on the lateral calf. C. Place a wedge pillow between the legs. D. Place a footboard on the bed.

Correct Answer is C

Explanation

An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.

Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar ﬂexion contractures.

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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 in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

Correct Answer is C

Explanation

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