A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority?
Morse Fall Risk scale
Braden scale
Pain assessment
Neurovascular assessment
The Correct Answer is D
A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.
Correct Answer is A
Explanation
A) Disposing of the top of the ampule in a sharps container is essential for safety to prevent accidental injuries from broken glass.
B) While placing a paper towel around the ampule's neck to break off the top with both hands is a good practice to prevent injury, it's not the primary action needed for safe disposal.
C) Expelling air into the ampule to aspirate air bubbles is unnecessary and could contaminate the medication.
D) Withdrawing the medication from the ampule using a needleless system is not typically done with ampules, as they are usually designed for single-use and require breaking the top off to access the medication.
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