The nurse is collecting data on a patient with a left tibia fracture. Which of the following findings is a priority finding?

Increased red blood cell count

Decreased lymphocyte count

Decreased body temperature

Absent left pedal pulse

Answer and Explanation

The Correct Answer is D

A. Increased red blood cell count: An increased red blood cell count is not an immediate concern in the context of a fracture.

B. Decreased lymphocyte count: A decreased lymphocyte count could indicate an infection or immune issue but is not the immediate priority in a fracture situation.

C. Decreased body temperature: Hypothermia can be concerning, but in the context of a fracture, it is not as critical as neurovascular compromise.

D. Absent left pedal pulse: An absent pedal pulse indicates a possible compromised circulation to the lower extremity, which is a critical and immediate concern. It could signify a compartment syndrome or arterial damage requiring urgent intervention.

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Correct Answer is B

Explanation

A. Explain the use of assistive devices. While explaining the use of assistive devices is important, it is not the primary preoperative care focus.

B. Clean skin with antibacterial skin cleaning cloths. Correct. Preoperative skin cleaning with antibacterial cloths is crucial to reduce the risk of postoperative infections.

C. Teach postoperative exercises. Teaching postoperative exercises is important but is typically part of preoperative education rather than immediate preoperative care.

D. Ask if a consent form was signed. Ensuring that consent forms are signed is necessary but is not the primary preoperative care focus.

A. Apply heat during the first 24 hr. B. Place moderate weight on the affected leg when walking. C. Elevate the affected ankle to the level of the heart. D. Apply the elastic compression dressing tight enough so the toes and ankle become numb.

Correct Answer is C

Explanation

A. Apply heat during the first 24 hr. Applying heat can increase swelling and should be avoided initially. Ice is recommended to reduce swelling.

B. Place moderate weight on the affected leg when walking. The affected leg should not bear weight until the initial acute phase of the injury has passed and pain/swelling has decreased.

C. Elevate the affected ankle to the level of the heart. Correct. Elevating the ankle helps to reduce swelling and promote venous return.

D. Apply the elastic compression dressing tight enough so the toes and ankle become numb. The compression dressing should be snug but not so tight that it restricts blood flow, which can lead to numbness and further injury.

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The nurse is collecting data on a patient with a left tibia fracture. Which of the following findings is a priority finding?

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