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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
C. Education about the benefits of pain management, including how analgesics can improve postoperative activity levels by reducing pain and discomfort, helps to promote the patient's understanding and engagement in their own care.
D. Nurses should closely monitor the patient for both therapeutic effects and adverse effects of opioid administration when using PCA or any other opioid analgesic. Regular assessment allows for prompt identification and management of any complications or side effects.
A. Patient-controlled analgesia (PCA) is designed for the patient to self-administer pain medication according to their own needs and pain levels.
B. Opioid dosing should be individualized based on the patient's pain level and response to the medication. Some patients may require ongoing opioid analgesia for more than two days postoperatively, while others may be able to transition to alternative pain management strategies sooner.
E. Concerns about opioid addiction should not be assumed in all patients, especially those who have never received opioids before. Instead, the focus should be on assessing the patient's pain levels, response to pain medication, and any adverse effects.
Correct Answer is B
Explanation
B. Methamphetamine use can cause significant cardiovascular effects, including tachycardia, hypertension, and arrhythmias. Given the patient's presentation with an irregular heart rate and tachycardia, continuous cardiac monitoring through an ECG is essential to assess for any life-threatening arrhythmias or other cardiac complications.
A. Reorientation is important for patients who are disoriented, but in the case of a patient who has admitted to using methamphetamine and is exhibiting signs of agitation and tachycardia, the priority is to ensure the patient's safety and stabilize their condition.
C. While providing a calm environment is beneficial for patients who are agitated, it is not the most important action in this scenario.
D. Obtaining a comprehensive health history, including prior drug use, is important for understanding the patient's background and potential risk factors. However, in this acute situation where the patient is disoriented, agitated, and exhibiting signs of cardiovascular distress, the priority is to address the immediate medical needs and stabilize the patient's condition.
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