An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?

The client cries out when the nurse attempts to examine him.

The client is extremely confused and trying to get up.

The skin of one leg is cooler than that of the upper extremities,

One leg is shorter than the other and has a protruding bump on the side.

Answer and Explanation

The Correct Answer is D

This finding suggests that the client may have experienced a hip fracture. The shorter leg can be a result of the fractured bone, causing a misalignment or displacement. The protruding bump on the side can be a sign of a dislocated or fractured hip joint. It is important to assess and confirm this suspicion through appropriate diagnostic measures, such as X-rays, to provide the necessary medical intervention and management.

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Correct Answer is A

Explanation

A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.

B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.

C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.

D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.

A. Notify the healthcare provider that the client's pain is not well-managed B. Reassure the client that the pain and stress of the fracture will soon get better. C. Order a chest CT Computerized Tomography) to rule out a pulmonary embolus (PE). D. Notify the healthcare provider that the client may have a fat embolism

Correct Answer is D

Explanation

Fat embolism syndrome can occur when fat globules enter the bloodstream after a long bone fracture, such as a femur fracture. The fat globules can travel to the lungs and cause respiratory distress and decreased oxygen saturation. The symptoms observed in the client, including tachypnea (labored breathing), decreased oxygen saturation (88%), and the presence of petechiae (small red or purple spots) on the neck and anterior chest, are consistent with fat embolism syndrome.

Fat embolism syndrome is a serious condition that requires immediate medical attention. Notifying the healthcare provider allows for prompt evaluation, confirmation of the diagnosis, and initiation of appropriate treatment. This may involve further diagnostic tests such as a chest CT scan, as mentioned in one of the options, to rule out other potential causes or complications.

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An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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