ATI LPN Paediatrics Nursing Cohort 65 Proctored Exam
A nurse is caring for a client following an open reduction and internal fixation of a fractured femur.Which of the following findings is the nurse's priority?
Explanation & Rationale
Choice A rationaleHeadache could indicate various conditions but is not immediately life-threatening post-surgery. It may be due to medication or anesthesia but is not the priority.Choice B rationaleAltered level of consciousness (LOC) is a critical finding. It may indicate complications such as hemorrhage, fat embolism, or hypoxia, which require urgent assessment and intervention.Choice C rationaleMuscle spasms can be a common symptom post-surgery due to pain or positioning. While they need management, they do not take precedence over LOC changes.Choice D rationaleAn oral temperature of 37.7°C is slightly elevated but not alarming. It may be due to the body's normal inflammatory response post-surgery.
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