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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}

Explanation

A) Slight tenting of the skin indicates dehydration, which is consistent with both DKA and HHS.
B) The presence of ketones in the urine is a hallmark of DKA, as it indicates the body is using fat for energy due to a lack of insulin.
C) A pH of 7.30 is lower than the normal range, suggesting acidosis, which is characteristic of DKA.
D) A blood glucose level of 468 mg/dL is significantly higher than the normal range, which is a common finding in both DKA and HHS.
E) An elevated creatinine level indicates kidney dysfunction, which can be a result of dehydration seen in both DKA and HHS.

A. Instruct the client to sit on a rubber ring when seated in a chair. B. Raise the head of the client's bed to a 90° angle. C. Use moisturizing lotion while massaging the client's bony prominences. D. Place pillows between the client's knees when in a side-lying position.

Correct Answer is D

Explanation

A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}

Explanation

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

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