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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"xRanges":[413.765625,473.765625],"yRanges":[424.609375,484.609375]}
Explanation
A transverse colon colostomy is typically placed in the upper abdomen, either in the middle or toward the right side of the body. In the above scenario the best location will be B which is located along the path of the transverse colon. Point A would be suitable for an ileostomy while point B will be suitable for a sigmoid colostomy.
Correct Answer is C
Explanation
A) Distended jugular veins are associated with fluid overload, not dehydration.
B) Pitting, dependent edema is also associated with fluid overload, not dehydration.
C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.
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