This is the edited text:
A client has suffered from a femur fracture. What is the nurse’s priority assessment?
Pain
Medication history
Socioeconomic status
Pedal pulses
The Correct Answer is D
Choice A reason: This is not the priority assessment, but it is an important assessment for a client with a femur fracture. Pain is the unpleasant sensation that results from tissue damage or inflammation. Pain can affect the client's physical and psychological wellbeing and interfere with their recovery. The nurse should assess the client's pain level, location, quality, and duration using a valid and reliable pain scale. The nurse should also provide pain relief measures, such as medication, ice, elevation, or distraction, as ordered and as needed.
Choice B reason: This is not the priority assessment, but it is a relevant assessment for a client with a femur fracture. Medication history is the record of the drugs that the client is currently taking or has taken in the past, including prescription, overthecounter, herbal, or recreational drugs. Medication history can help the nurse identify any potential drug interactions, allergies, or contraindications that may affect the client's treatment and recovery. The nurse should ask the client about their medication history and document it accurately and completely.
Choice C reason: This is not the priority assessment, but it is a helpful assessment for a client with a femur fracture. Socioeconomic status is the measure of the client's income, education, occupation, and social class. Socioeconomic status can influence the client's access to health care, ability to afford treatment, compliance with therapy, and support system. The nurse should assess the client's socioeconomic status and provide appropriate referrals, resources, or assistance as needed.
Choice D reason: This is the priority assessment for a client with a femur fracture. Pedal pulses are the pulses that can be felt in the feet, such as the dorsalis pedis or the posterior tibial pulse. Pedal pulses can indicate the blood flow and perfusion to the lower extremities, which can be compromised by a femur fracture. A femur fracture can cause bleeding, swelling, or pressure that can reduce or obstruct the blood supply to the feet, leading to ischemia, necrosis, or gangrene. The nurse should assess the client's pedal pulses regularly and report any changes, such as absent, weak, or thready pulses. The nurse should also monitor the client's skin color, temperature, sensation, and movement in the feet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Allowing the client to sleep to build up stamina is not the priority intervention, because it does not address the psychosocial needs of the client. Sleeping is a physiological need, not a psychosocial need. Sleeping may help the client recover physically, but it does not help the client cope emotionally or socially with the isolation.
Choice B reason: Maintaining a sixfoot distance from the client is not the priority intervention, because it does not enhance the psychosocial needs of the client. Maintaining a sixfoot distance from the client is a safety measure, not a psychosocial intervention. Maintaining a sixfoot distance from the client may help prevent the transmission of infection, but it does not help the client feel less lonely or isolated.
Choice C reason: Providing a timeframe for the isolation is not the priority intervention, because it does not enhance the psychosocial needs of the client. Providing a timeframe for the isolation is an informational intervention, not a psychosocial intervention. Providing a timeframe for the isolation may help the client understand the rationale and duration of the precautions, but it does not help the client feel more engaged or supported.
Choice D reason: Providing the client with diversional activities is the priority intervention, because it enhances the psychosocial needs of the client. Providing the client with diversional activities is a psychosocial intervention, not a physiological, safety, or informational intervention. Providing the client with diversional activities may help the client feel more entertained, stimulated, and connected with others, which can reduce the negative effects of isolation.
Correct Answer is D
Explanation
Choice A reason: Use gentle brushing and flossing techniques for clients with fragile mucosa is an important nursing intervention, but it is not the priority. Gentle brushing and flossing can help prevent plaque, gingivitis, and infection in the oral cavity, especially for clients with fragile mucosa due to dehydration, medication, or radiation. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.
Choice B reason: Handle dentures with care is an important nursing intervention, but it is not the priority. Handling dentures with care can prevent damage, loss, or misplacement of the dentures, which can affect the client's comfort, appearance, and nutrition. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.
Choice C reason: Position the client on one side with the head turned towards you is an important nursing intervention, but it is not the priority. Positioning the client on one side with the head turned towards you can facilitate the access and visibility of the oral cavity, as well as prevent the aspiration of saliva, blood, or debris. However, this intervention is not as effective as having a suction apparatus ready at the bedside.
Choice D reason: Have a suction apparatus ready at the bedside is the priority nursing intervention, because it can prevent the aspiration of saliva, blood, or debris, which can cause choking, pneumonia, or respiratory distress. Having a suction apparatus ready at the bedside can allow the nurse to quickly and safely remove any secretions or foreign materials from the oral cavity or the airway of the unconscious client.
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