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 D
Explanation
Choice A rationale
Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.
Choice B rationale
Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.
Choice C rationale
Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.
Choice D rationale
Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.
Correct Answer is B
Explanation
Choice A rationale
While it’s always important to inform the medical team of any allergies, there’s no specific link between shellfish or iodine allergies and cystoscopy.
Choice B rationale
After a cystoscopy, patients should report any instances of painful urination, blood in urine, or fever. These could be signs of complications such as infection.
Choice C rationale
There’s no specific need for patients to refrain from strenuous activities and sports for at least 2 weeks after a cystoscopy.
Choice D rationale
Remaining in a prone position for 24 hours after the procedure is not a standard recommendation following a cystoscopy.
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