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

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.

A. Assess the temperature of the affected extremity. B. Adjust the prescribed weights every shift. C. Examine the skin under the traction splint. D. Monitor peripheral pulses in the affected extremity. E. Position weights against the foot of the bed.

Correct Answer is ["A","C","D"]

Explanation

A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.

C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.

D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.

B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.

E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.

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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

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