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.
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Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A) The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B) The client’s respiratory rate decreased from 24/min to 22/min.
C) The client’s heart rate decreased from 120/min to 100/min.
D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.
F) Only one echocardiogram result showing myocardial infarction was provided.
G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.
Correct Answer is B
Explanation
A) Limiting time for visitors is necessary in this case. However, the time should be limited to 1 hour in 24 hours and not 2 hours.
B) Instructing visitors to remain 6 feet from the client is crucial for their safety to minimize radiation exposure. Brachytherapy involves the use of a radioactive source placed close to or inside the tumor, and while the patient is emitting radiation, safety precautions must be taken to protect others from exposure. Safety measures such as maintaining a safe distance help ensure that the radiation exposure to others is As Low As Reasonably Achievable (ALARA), a principle that aims to minimize exposure while achieving the necessary therapeutic effect.
C) Discarding the radioactive device in the client's trash can is incorrect as it poses a risk of exposure to others.
D) Keeping soiled bed linens in the client's room is incorrect as they may be contaminated with radiation and should be handled according to radiation safety protocols.
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