The nurse is assessing a client and find their right leg is shortened, adducted and externally rotated. These assessment findings would indicate which type of injury?

Pelvic fracture

Femoral neck fracture

Tibia fracture

Fibula fracture

Answer and Explanation

The Correct Answer is B

A. Pelvic fracture: Pelvic fractures may cause significant pain and instability but do not typically result in a shortened, adducted, and externally rotated leg.

B. Femoral neck fracture: These findings (shortened, adducted, externally rotated leg) are classic for a femoral neck fracture due to muscle contraction and displacement of the bone.

C. Tibia fracture: Tibia fractures typically present with swelling and deformity, not shortening or rotation of the leg.

D. Fibula fracture: A fibula fracture alone rarely causes leg shortening or rotation as it is a non-weight-bearing bone.

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Correct Answer is C

Explanation

A. Call the physician: While notifying the physician is important, it is not the immediate priority in a life-threatening situation like ventricular fibrillation.

B. Administer oxygen: Administering oxygen is helpful, but the immediate priority in ventricular fibrillation is to initiate life-saving measures.

C. Initiate cardiopulmonary resuscitation (CPR): Ventricular fibrillation is a life-threatening emergency, and initiating CPR immediately is crucial to restore circulation and improve chances of survival.

D. Give a dose of epinephrine: Epinephrine is part of the advanced cardiac life support (ACLS) protocol, but it should be administered after initiating CPR and defibrillation.

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. B. The new graduate nurse administers an analgesic before turning the client. C. The new graduate nurse is frequently suctioning the client without breaks. D. The new graduate nurse assesses the client's neurologic status every hour.

Correct Answer is C

Explanation

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

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The nurse is assessing a client and find their right leg is shortened, adducted and externally rotated. These assessment findings would indicate which type of injury?

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