A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Provide optimal nutrition and hydration.

Provide relief from pain and discomfort.

Maintain immobilization and alignment.

Promote independence in activities of daily living.

Answer and Explanation

The Correct Answer is C

C. Maintaining immobilization and alignment of the fractured bone is essential for allowing the bone to heal properly. Immobilization prevents further injury and displacement of the fracture fragments, while proper alignment ensures optimal bone healing and functional outcomes.

A. Optimal nutrition and hydration may not be the highest priority compared to other interventions that directly address the fracture management and functional healing.

B. Providing relief from pain and discomfort is crucial for the client's comfort and well-being, but it may not be the highest priority in achieving functional healing.

D. Promoting independence in activities of daily living is important for the client's overall well-being and quality of life, but it may not be the highest priority immediately after a fracture.

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Correct Answer is B

Explanation

B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.

A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.

C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.

D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.

A. Explain the discharge instructions to the client and parents. B. Apply an ice pack to the casted leg. C. Perform a neurovascular assessment. D. Provide reassurance to the client and parents.

Correct Answer is C

Explanation

C. A neurovascular assessment involves evaluating the circulation, sensation, and movement of the limb distal to the cast to ensure there are no signs of neurovascular compromise, such as decreased pulses, numbness, tingling, or weakness. Prompt identification of any neurovascular impairment is essential for preventing complications such as compartment syndrome.

A. Explaining discharge instructions is important for ensuring the client and their parents understand how to care for the cast at home. However, it is not the priority action.

B. Applying an ice pack to the casted leg can help reduce swelling and provide pain relief, but it is not the priority action immediately after the cast application.

D. Providing reassurance is important for alleviating anxiety and promoting a positive experience for the client and their parents. However, it is not the priority action.

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A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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