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. Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B. Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C. Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.

A. A patient who had a tonsillectomy one week ago B. A patient who had a knee replacement surgery this morning C. A patient who had a hernia repair surgery yesterday D. A patient who had an appendectomy two days ago

Correct Answer is D

Explanation

D. Appendectomy is a common surgical procedure to remove the appendix and is considered a moderate surgical intervention. Early ambulation is generally encouraged for patients after appendectomy to prevent complications such as pneumonia, deep vein thrombosis, and ileus.

B. Knee replacement surgery is a major orthopedic procedure that requires early mobilization and rehabilitation to prevent complications such as blood clots, joint stiffness, and muscle weakness. However, the client needs more time before ambulation is initiated

A. Tonsillectomy is a relatively minor surgical procedure that typically does not significantly impact a patient's mobility or ability to ambulate. The patient who had a tonsillectomy one week ago is likely well-recovered and may not require immediate prioritization for ambulation.

C. Hernia repair surgery is typically considered a moderate surgical procedure. While early mobilization is generally beneficial for patients recovering from hernia repair surgery, it may not be as urgent as for patients undergoing major orthopedic surgeries like knee replacement.

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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

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Correct Answer is D

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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?