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A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority?

A.

Morse Fall Risk scale

B.

Braden scale

C.

Pain assessment

D.

Neurovascular assessment

Answer and Explanation

The Correct Answer is D

A)    The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B)    The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C)    Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D)    The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.
 


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Related Questions

Correct Answer is C

Explanation

A) Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B) Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C) This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D) Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.

Correct Answer is D

Explanation

A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.

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