An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?

Right leg externally rotated and shorter than left.

Wiggles right foes when sole of right foot is tickled.

Left lower extremity is warm to touch.

Bilateral pedal pulses present and strong.

Answer and Explanation

The Correct Answer is A

A. The right leg being externally rotated and shorter than the left is a classic sign of a hip fracture and should be reported for further evaluation and management.

B. The ability to wiggle the right toes indicates that some nerve function is intact and is not a concerning finding in this context.

C. A warm left lower extremity could indicate circulation but is not as urgent as a potential fracture finding.

D. Strong bilateral pedal pulses are a positive sign, suggesting adequate blood flow, and do not require immediate reporting.

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Correct Answer is B

Explanation

A. While measuring vital signs is important, it does not directly address the client's immediate difficulty in breathing. Prioritizing the client's comfort and respiratory function is more critical in this situation.

B. Assisting the client to a high Fowler's position helps facilitate lung expansion and may alleviate dyspnea. This position can improve respiratory function by reducing abdominal pressure on the diaphragm.

C. Deep breathing exercises are beneficial but are not the immediate priority; positioning the client for better airflow should come first.

D. Auscultating breath sounds is necessary for assessing the underlying cause of dyspnea, but this should be done after ensuring the client is in a position that maximizes their breathing capacity.

A. Identify information as late entry in the record. B. Notify information services department of the situation. C. Print electronic medical record (EMR) from backup server. D. Wait for notification that the system has been rebooted.

Correct Answer is B

Explanation

A. Identifying information as a late entry may be necessary later, but it does not address the immediate issue of the system failure.

B. Notifying the information services department is critical as they can assist in troubleshooting the issue and may expedite the restoration of the system.

C. Printing the EMR from a backup server may be necessary, but it is not the first step; the system's functionality should be confirmed first.

D. Waiting for notification is not proactive and could delay necessary patient care and documentation.

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An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?

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