A 72-year-old patient with osteoporosis is admitted to the emergency department after falling at home and sustaining a hip fracture. The patient is experiencing severe pain and has visible shortening and external rotation of the affected leg. Which nursing action should be the FIRST priority?
1Administer prescribed pain medication to manage severe pain
2Apply Buck's traction to stabilize the fracture site
3Assess neurovascular status of the affected extremity✓ 정답
4Prepare the patient for immediate surgical intervention
해설
Neurovascular assessment is the first priority to detect complications like compartment syndrome or vascular compromise that can cause permanent damage. Pain management, traction, and surgery preparation are important but secondary after ensuring limb viability.
When a patient presents with a hip fracture, the classic clinical picture includes severe pain, a shortened limb, and external rotation. While these signs strongly suggest a fracture, the immediate nursing priority is not to treat the assumed injury but to establish a baseline and rule out a limb-threatening complication. The NCLEX-RN consistently tests the principle that assessment precedes intervention, particularly when an intervention could mask critical changes or cause harm.
Why Neurovascular Assessment is the First Priority
The correct action is to assess neurovascular status of the affected extremity. A displaced hip fracture can compromise the surrounding neurovascular bundle. The femoral head’s displacement can impinge on or lacerate the femoral artery or sciatic nerve, leading to ischemia or permanent nerve damage. This assessment involves checking the six Ps: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia. Obtaining a baseline neurovascular status is critical before any manipulation, traction, or medication administration that could alter sensation or circulation. Without this initial data, a subsequent loss of a pulse or sensation cannot be accurately timed or attributed, delaying critical vascular or neurologic intervention.
Physiological Rationale and Fracture Risk
Osteoporosis is a systemic skeletal disorder characterized by an imbalance in bone homeostasis, reduced bone mass, and microarchitectural deterioration of bone tissue, which leads to increased bone fragility and a higher risk of fractures [1]. In this patient, the underlying osteoporotic bone pathology is the direct cause of the hip fracture from a low-energy fall. The microarchitectural deterioration means the bone’s trabecular network is weakened, making it susceptible to displacement and the sharp, jagged edges of a fracture that can easily damage adjacent soft tissues, including nerves and blood vessels. This pathophysiological link between the disease process and the acute injury underscores why a thorough neurovascular check is the foundational first step in clinical management.
Analysis of Other Options
Administering prescribed pain medication (Option 1) is an important comfort measure but is not the first priority. Pain medication can mask a critical symptom—paresthesia or increasing pain from compartment syndrome or nerve compression. The nurse must first document the presence and quality of sensation and pain before administering analgesics. Applying Buck's traction (Option 2) is a therapeutic intervention to reduce muscle spasm and stabilize the fracture, but applying traction before a neurovascular assessment could worsen an undetected nerve or vascular injury. The limb’s baseline circulatory and neurological function must be confirmed first. Preparing for immediate surgical intervention (Option 4) is a downstream task. While surgical repair is the definitive treatment, the nurse’s immediate, independent role at the bedside is to perform a focused assessment and recognize life- or limb-threatening complications. The nursing process dictates that assessment is the first step, and all subsequent actions depend on its findings.
References (research sources)
[1]
Artificial Intelligence for Osteoporosis Diagnosis, Risk Prediction and Therapy: Current Advances, Clinical Challenges, and Future Perspectives.Research articleZhang Z, He Y, Mo Z, Zhang P, Tian Z, Huang L. (2026) · DOI: 10.2147/cia.s607232
Clinical Guide: Hip Fracture Initial Triage
Priority Nursing Actions
First Priority: Perform a comprehensive neurovascular assessment of the affected extremity immediately upon presentation. Document baseline findings including pulses, capillary refill, sensation, and motor function.
Pain Management: Administer prescribed analgesia only after the initial neurovascular assessment is completed and documented to avoid masking critical changes.
Stabilization: Apply gentle traction (e.g., Buck's traction) only after confirming adequate neurovascular status to prevent further displacement or vascular compromise.
Surgical Preparation: Prepare the patient for surgery while continuously monitoring and reassessing neurovascular status at frequent intervals as per facility protocol.
Neurovascular Assessment Components
Pulses: Palpate dorsalis pedis and posterior tibial pulses; compare to the unaffected side.
Capillary Refill: Assess capillary refill time; normal is less than 3 seconds.
Sensation: Test light touch and pinprick sensation in the foot and lower leg to rule out nerve impingement.
Motor Function: Ask the patient to wiggle toes or dorsiflex/plantarflex the foot if pain allows.
Color and Temperature: Note any pallor, cyanosis, or temperature differences compared to the unaffected limb.
Critical Alerts
Compartment Syndrome: Monitor for increasing pain unrelieved by medication, paresthesia, and tensely swollen limb. Report immediately.
Vascular Injury: Loss of previously palpable pulses or sudden onset of pallor and coolness requires emergent vascular consultation.
Nerve Injury: New onset of foot drop or loss of sensation indicates possible sciatic or peroneal nerve compression.
Neurovascular Assessment — Evaluation of nerve and blood supply to an extremity, typically using the six Ps: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.
Hip Fracture Clinical Presentation — Classic signs include severe pain, shortening of the affected leg, and external rotation, often resulting from a fall in patients with osteoporosis.
Osteoporosis — A systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration, leading to increased bone fragility and fracture risk.