An elderly patient who had a fall at a store is admitted with a potential right hip fracture.
What assessment finding should the nurse report to the healthcare provider?
The left lower extremity is warm to touch.
Bilateral pedal pulses are present and strong.
The patient wiggles their right toes when the sole of the right foot is tickled.
The right leg is externally rotated and shorter than the left.
The Correct Answer is D
Choice A rationale
While it’s important to assess all aspects of the patient’s condition, a warm left lower extremity does not necessarily indicate a right hip fracture. It could be related to other conditions, such as deep vein thrombosis or cellulitis.
Choice B rationale
The presence of strong bilateral pedal pulses is a positive sign and does not indicate a hip fracture. It suggests that the patient has good peripheral circulation.
Choice C rationale
The ability to wiggle the toes when the sole of the right foot is tickled does not necessarily indicate a hip fracture. This is a normal response and suggests that the patient has intact sensory and motor function in the foot.
Choice D rationale
A right leg that is externally rotated and shorter than the left is a classic sign of a hip fracture. This occurs because the fracture can cause the femoral head to tilt and rotate outward, making the leg appear shorter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.
Choice B rationale
Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.
Choice C rationale
Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.
Choice D rationale
Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.
Correct Answer is ["C","D"]
Explanation
Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:
- C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
- D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.
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