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. If the patient expresses confusion or uncertainty about the surgical procedure, the nurse should notify the surgeon or appropriate healthcare provider promptly. The surgeon may need to revisit the discussion with the patient, clarify any misunderstandings, and answer any questions to ensure informed consent.

A. This option involves the nurse providing the patient with a comprehensive explanation of the planned surgical procedure, including the purpose, risks, benefits, and alternatives. That however, is the role of the provider.

C. While the operating room nurse may have knowledge about the planned surgical procedure, it is ultimately the responsibility of the surgeon or healthcare provider performing the procedure to ensure that the patient understands and consents to the surgery.

D. Administering preoperative antibiotics and managing sedative medications are important aspects of preoperative care but are not directly related to addressing the patient's concerns about understanding the planned surgical procedure.

A. Inability to move toes. B. Pallor of the toes. C. Edema of the toes. D. Change in temperature of the toes.

Correct Answer is B

Explanation

B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.

A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.

C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.

D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.

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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

Naxlex Comprehensive Predictor Exams

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