A nurse is contributing 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.

a. 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.
b. 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.
d. 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 D

Explanation

a. Auscultation of lungs revealing wheezing is not related to venous return in the aﬀected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.

b.A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.

c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.

d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.

A. Toes cool to touch B. Inability to move toes C. Pallor of the toes D. Edema of the toes

Correct Answer is A

Explanation

The correct answer is choice A: Toes cool to touch.

Choice A rationale: When a cast is too tight, it can compromise blood circulation to the extremity. This results in decreased blood flow and reduced oxygenation, causing the toes to feel cool to the touch.

Choice B rationale: Inability to move toes is a significant concern that can also indicate nerve compression due to a tight cast. However, it may not be the first sign of a tight cast, as impaired blood circulation will likely be evident before nerve damage.

Choice C rationale: Pallor of the toes, or a pale appearance, can occur when there is restricted blood flow. However, the coolness of the toes is often noticeable before pallor develops.

Choice D rationale: Edema of the toes, or swelling, can occur due to a tight cast, but it is usually a later sign. Initially, the toes may feel cool to the touch, followed by other symptoms such as pallor, pain, and eventually, swelling.

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A nurse is contributing 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 collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the aﬀected arm?

Correct Answer is D

Explanation

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

Correct Answer is A

Explanation

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