A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Obtain a prescription to adjust the weight amount.

Realign the client's position.

Offer a muscle relaxant to the client.

Administer an opioid analgesic.

Answer and Explanation

The Correct Answer is B

B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.

A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.

C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.

D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.

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Correct Answer is B

Explanation

B. Acute compartment syndrome occurs when increased pressure within a muscle compartment compromises circulation to the muscles and nerves within that compartment. Fractures, especially those accompanied by significant soft tissue injury or bleeding, can lead to compartment syndrome.

A Osteomyelitis is an infection of the bone that can occur as a complication of fractures, particularly if the fracture is open (the bone breaks through the skin). This occurs in the later courses of an infection.

C Fat embolism syndrome occurs when fat globules from fractured bones enter the bloodstream and become lodged in small blood vessels in organs such as the lungs, brain, and skin. Increasing edema is not an early sign of fat embolism.

D Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow. While fractures, especially long bone fractures, can increase the risk of developing blood clots, increasing edema in the fractured limb is not typically an early sign of pulmonary embolism.

A. The bone is cracked lengthwise but did not break all the way through. B. Fragments of bone have splintered into the surrounding tissue. C. The bone ends have been forced toward each other. D. Sharp edge of the bone has broken through the skin.

Correct Answer is A

Explanation

This description accurately reflects a greenstick fracture. In a greenstick fracture, the bone is partially fractured, typically on one side, while the other side remains intact. It is often compared to the way a green stick bends but does not break completely.

This description is more characteristic of a comminuted fracture, where the bone breaks into multiple fragments that may displace or splinter into the surrounding tissue.

This description is indicative of an impacted fracture, where the bone ends are driven into each other, often due to a compressive force.

This description is characteristic of an open or compound fracture, where the broken bone penetrates the skin and is exposed to the external environment.

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A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Nursing Test Bank

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