A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

Muscle spasms

Hip pallor

Leg abduction

Leg lengthening

Answer and Explanation

The Correct Answer is A

A.   Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B.   Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C.   Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.

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Correct Answer is A

Explanation

A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.

B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.

C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.

D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.

A. Report any worsening or unrelieved pain. B. Avoid moving the affected leg. C. Use a cotton swab to relieve itching under the cast. D. Use a blow dryer on a moderate heat setting to dry the cast after showering.

Correct Answer is A

Explanation

A. Reporting any worsening or unrelieved pain is important because increasing or unrelieved pain could indicate complications such as inadequate immobilization, pressure sores, or compartment syndrome. Prompt reporting allows for timely intervention and prevention of further complications

B. Movement of the affected leg could disrupt the alignment of the bones and impede the healing process. Immobilization is essential for bone healing in a fiberglass cast. However, reporting features of compartment syndrome is priority.

C. Patients should be advised not to insert anything under the cast and instead use other methods such as blowing cool air under the cast or gently tapping on the outside of the cast to relieve itching.

D. Using a blow dryer on a moderate heat setting can help speed up the drying process of the cast after it gets wet. However, it's important to ensure that the heat is not too high to avoid causing burns or softening the cast material excessively.

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A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

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