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

Explanation

A. A palpable thrill over the graft site indicates adequate blood flow through the graft.

B. The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C. Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D. A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.

A. Cover electrical outlets in the client's home with tape. B. Keep the client's bedroom dark at night. C. Hang a monthly calendar in the client's bedroom. D. Place a large-face clock in the client's bedroom.

Correct Answer is D

Explanation

A. Covering electrical outlets with tape may not be sufficient for safety and could pose a fire hazard. Safety covers designed for outlets are recommended.
B. Keeping the client's bedroom dark at night may increase confusion and disorientation. Soft lighting or nightlights are preferable.
C. While a calendar may be helpful, placing it in the client's bedroom may not be as beneficial as placing it in a common area where the client spends time during the day.Furthermore, amonthly calendar can be too complex for clients with Alzheimer’s disease, especially in the later stages. Simpler tools like a daily schedule or a weekly calendar are more effective.
D. A large-face clock can help the client orient to time and reduce confusion regarding the time of day.

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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

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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