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 A

Explanation

A. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant concern following knee replacement surgery due to the increased risk of blood clot formation associated with immobility and surgery. Limited mobility can predispose the patient to stasis of blood flow, which increases the risk of VTE.

B. While fluid and electrolyte imbalance can occur postoperatively, especially if the patient experiences complications such as excessive bleeding or fluid shifts, limited mobility alone is less likely to directly lead to this complication as a priority.

C. Limited mobility can potentially impact surgical wound healing by delaying the resolution of edema, impairing circulation, and increasing the risk of infection. However, this complication may not be as immediate or life-threatening as others on the list.

D. Hypovolemic shock, characterized by inadequate tissue perfusion due to decreased circulating blood volume, is a severe complication that can result from significant blood loss. While bleeding can occur postoperatively, it is less common as a complication of knee replacement surgery, especially within the first few days.

A. Tympanic temperature 99.2° F (37.3° C) B. Fine crackles audible at both lung bases C. 200 mL sanguineous fluid in the wound drain D. Redness and swelling along the suture line

Correct Answer is C

Explanation

C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock

A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).

B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.

D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.

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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?

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