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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
D. Tachypnea is a classic early manifestation of fat embolism syndrome. Fat emboli can travel to the lungs and obstruct blood flow, leading to respiratory distress and hypoxemia. Tachypnea is the body's response to hypoxemia, as it attempts to increase oxygen intake by breathing more rapidly.
A. Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), but it is not typically an early manifestation of fat embolism syndrome.
B. tachycardia is more commonly seen due to the body's response to decreased oxygen levels and increased demand on the cardiovascular system.
C. Hypertension is not typically associated with fat embolism syndrome. Instead, hypotension can occur due to decreased cardiac output and systemic vasodilation in severe cases of fat embolism syndrome.
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