A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Provide optimal nutrition and hydration.

Provide relief from pain and discomfort.

Maintain immobilization and alignment.

Promote independence in activities of daily living.

Answer and Explanation

The Correct Answer is C

C. Maintaining immobilization and alignment of the fractured bone is essential for allowing the bone to heal properly. Immobilization prevents further injury and displacement of the fracture fragments, while proper alignment ensures optimal bone healing and functional outcomes.

A. Optimal nutrition and hydration may not be the highest priority compared to other interventions that directly address the fracture management and functional healing.

B. Providing relief from pain and discomfort is crucial for the client's comfort and well-being, but it may not be the highest priority in achieving functional healing.

D. Promoting independence in activities of daily living is important for the client's overall well-being and quality of life, but it may not be the highest priority immediately after a fracture.

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Correct Answer is A

Explanation

A. Preventing hip flexion of the affected extremity is often a key component of postoperative care following total hip arthroplasty. This helps prevent dislocation of the new hip joint and promotes proper healing.

B. While some caution is necessary to prevent excessive movement that could strain the surgical site, complete avoidance of movement in the affected leg is not recommended.

C. Ensuring that the client's heels are touching the bed is not typically a specific intervention related to postoperative care following total hip arthroplasty.

D. Positioning the lower extremities so that they are touching is not typically a specific intervention related to postoperative care following total hip arthroplasty.

A. Increase the oxygen flowrate. B. Elevate the patient's head on two pillows. C. Suction the patient's mouth. D. Perform the jaw-thrust maneuver.

Correct Answer is A

Explanation

A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.

B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.

C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.

D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.

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A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?

Correct Answer is A

Explanation

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