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?

Morse Fall Risk scale

Braden scale

Pain assessment

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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Correct Answer is A

Explanation

A. A palpable thrill over the graft site indicates adequate blood flow through the graft.

B. The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C. Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D. A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.

A. Pad the upper two side rails of the client's bed. B. Maintain peripheral IV access. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside. E. Keep a padded tongue blade at the client's bedside.

Correct Answer is A

Explanation

A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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