A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

Promote independence in activities of daily living for the client.

Provide relief from pain and discomfort for the client.

Maintain immobilization and alignment for the client.

Provide optimal nutrition and hydration for the client.

Answer and Explanation

The Correct Answer is C

When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly and can prevent complications such as malunion or nonunion.

Promoting independence in activities of daily living for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

Providing relief from pain and discomfort for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

Providing optimal nutrition and hydration for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

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Correct Answer is A

Explanation

If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreﬂexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.

Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.

Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.

Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreﬂexia.

A. Maintain the client on bed rest for 72 hr after surgery. B. Check capillary refill in the aﬀected extremity every 4 hr. C. Restrict oral ﬂuid intake to 1,000 ml per day. D. Remove antiembolic stockings once each day to examine skin integrity.

Correct Answer is B

Explanation

Checking capillary refill in the aﬀected extremity every 4 hr is an important intervention for a nurse to include in the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. This helps to monitor the blood flow to the aﬀected extremity and ensure that it is adequate.

a. Maintaining the client on bed rest for 72 hr after surgery is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's mobility should be determined by their individual needs and the surgeon's instructions.

c. Restricting oral ﬂuid intake to 1,000 ml per day is not necessary for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's ﬂuid intake should be determined by their individual needs and any medical conditions they may have.

d. Removing antiembolic stockings once each day to examine skin integrity is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The use of antiembolic stockings and their removal should be determined by the patient's individual needs and the surgeon's instructions.

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A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?

A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

A nurse in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

A nurse in a clinic is collecting data from an older adult client who has a new diagnosis of osteoarthritis. Which of the following medications should the nurse anticipate the provider will initially prescribe to the client?