A nurse is caring for a client who sustained a posterior hip dislocation following a motor vehicle accident. The client reports severe pain and inability to move the affected leg, which appears shortened and internally rotated. Which nursing intervention should be the priority?

Immediate immobilization in supine position is priority for posterior hip dislocation to prevent further injury and complications like avascular necrosis or sciatic nerve damage. Other interventions such as ice or pain medication are secondary.

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a patient with a traumatic posterior hip dislocation. The key is understanding the pathophysiology of the injury and the principles of emergency musculoskeletal care. In a posterior dislocation, the femoral head is forced out of the acetabulum backward, often tearing the joint capsule and surrounding ligaments. The classic presentation is a shortened, internally rotated, and adducted leg. The most critical immediate threat is further damage to the sciatic nerve (which runs posteriorly) and the femoral head blood supply, which can lead to avascular necrosis (AVN).

Answer Rationale: Key Point! The priority is immobilization to prevent further neurovascular injury and prepare for definitive treatment (reduction). Option ④, "Maintain the client in supine position and immobilize the affected leg," directly addresses this. Immobilization in a neutral position prevents further displacement that could compress the sciatic nerve or compromise blood vessels. This aligns with the RICE principle (Rest, Ice, Compression, Elevation) for acute musculoskeletal injuries, where "Rest" (immobilization) is the first step.

Distractor Analysis:

• Option ① (Apply ice packs): While applying ice is a correct intervention for reducing swelling and pain, it is secondary to immobilization. Performing this first could involve moving the limb, causing further harm.
• Option ② (Administer pain medication): Pain management is crucial for patient comfort and can reduce muscle spasms. However, it does not address the primary problem of structural instability and risk of neurovascular compromise. It is important, but not the first action.
• Option ③ (Encourage early ambulation): This is contraindicated and dangerous for a dislocated joint. Ambulation on an unreduced dislocation can cause severe damage to cartilage, nerves, and blood vessels, significantly worsening the prognosis.

Related Concepts: This scenario integrates trauma nursing principles (prioritizing stability), orthopedic emergency care, and neurovascular assessment. After immobilization, the nurse's next priorities include frequent neurovascular checks (assessing pulses, capillary refill, sensation, and movement distal to the injury) and preparing the patient for closed reduction, often under sedation.

Concept Summary

Concept	Key Takeaway
Posterior Hip Dislocation	Femoral head displaced posteriorly. Classic signs: Hip flexed, knee flexed, leg shortened & internally rotated.
Priority Intervention	Immediate immobilization to prevent sciatic nerve injury and avascular necrosis of the femoral head.
Nursing Process	Assessment (neurovascular status) → Diagnosis (risk for injury) → Planning/Implementation (immobilize, monitor) → Evaluation (stable status pre-reduction).
Contraindicated Action	Do NOT attempt to reduce the dislocation or encourage weight-bearing/movement.

Side-by-Side Comparison!

Injury	Mechanism	Classic Presentation	Key Nursing Priority
Posterior Hip Dislocation	Force applied to a flexed knee (e.g., dashboard injury in MVA).	Leg: Shortened, Internally Rotated, Adducted. Hip in flexion.	Immobilize. Monitor for sciatic nerve injury (foot drop, loss of sensation).
Anterior Hip Dislocation (Less Common)	Force with hip extended and abducted.	Leg: Externally Rotated, Abducted. May appear lengthened.	Immobilize. Monitor for femoral nerve/vessel injury.
Hip Fracture (e.g., Femoral Neck)	Fall, direct trauma, osteoporosis.	Leg: Shortened, Externally Rotated. Severe pain with any movement.	Immobilize (traction). Priority is also pain management and prep for surgery.

Anatomy, Physiology & Pharmacology Points

• Anatomy: The sciatic nerve exits the pelvis via the greater sciatic foramen and runs posterior to the hip joint. In a posterior dislocation, it is at direct risk of compression or stretch injury.
• Physiology: The medial femoral circumflex artery is the primary blood supply to the femoral head. Disruption can lead to avascular necrosis (AVN), making timely reduction (< 6 hours) critical.
• Pharmacology: Pain medication (often IV opioids like morphine) and muscle relaxants or sedation (like midazolam) will be administered after immobilization, typically in preparation for a closed reduction procedure.

Memory Tips

• Acronym for Posterior Dislocation Signs: "SIA" – Shortened, Internally rotated, Adducted.
• Priority Action Mnemonic: "DON'T MOVE, IMMOBILIZE!" For any major joint dislocation or fracture, the first rule is to stabilize the injury site before doing anything else.
• Think of the mechanism: "Dashboard injury" (knee hits dashboard) = force up the femur = posterior hip dislocation.

High-Frequency NCLEX Topics The NCLEX loves to test priority-setting in trauma and orthopedic emergencies. You must distinguish between a correct intervention and the first or most important intervention. Remember the hierarchy: Stabilize life-threatening issues (ABCs) → Stabilize the injury (immobilize) → Manage symptoms (pain, swelling) → Prevent complications.
Watch Out for Question Variations!

• Shift from "Intervention" to "Assessment": "Which finding should the nurse report immediately?" Answer: Signs of sciatic nerve injury (e.g., inability to dorsiflex the foot/foot drop, numbness in the posterior leg/foot).
• Shift to Post-Reduction Care: After the dislocation is reduced, the priority may shift to "maintaining abduction" with a pillow or brace to prevent re-dislocation and "continuing neurovascular checks."
• Pharmacology Focus: "The client is scheduled for closed reduction. Which medication should the nurse anticipate administering prior to the procedure?" Answer: Sedatives and analgesics.

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the Emergency Department (ED). A 28-year-old male is brought in via ambulance after a head-on collision. He was the driver. His primary survey (ABCs) is stable. He is alert but in severe distress, clutching his right hip. You observe his right leg is clearly shorter than the left and turned inward.

Nursing Intervention Strategy:

1. Immediate Action (Priority): Instruct the patient, "Try not to move your right leg." Gently place rolled towels or blankets alongside the limb to maintain its current position. Do not attempt to straighten or realign it. This is the immobilization in option ④.
2. Assessment: Once immobilized, perform a focused neurovascular assessment every 15 minutes:
   • Circulation: Check pedal pulses (dorsalis pedis, posterior tibial), capillary refill (< 3 seconds), and skin color/temperature.
   • Sensation: Ask, "Can you feel me touching the top and bottom of your foot?" Check light touch sensation in dermatomes served by the sciatic nerve (e.g., sole of foot).
   • Motion: Ask, "Can you wiggle your toes and push your foot down and up against my hand?" This tests motor function of the peroneal and tibial nerves (branches of sciatic).
3. Collaboration & Preparation: Notify the physician/ED provider immediately. Anticipate orders for:
   • IV access and labs.
   • Pain medication (e.g., morphine IV) after immobilization.
   • X-rays/CT scan to confirm diagnosis and rule out fracture.
   • Preparation for closed reduction in the ED or OR.
4. Comfort & Education: Explain all procedures to the patient. Apply ice packs around (not directly on) the immobilized hip to reduce swelling, once it is secure.

Patient Safety and Precautions:

• Absolute Contraindication: Never apply longitudinal traction or attempt to "pop" the hip back in. This is outside the RN's scope and can cause severe neurovascular damage.
• Medication Caution: Administer opioids cautiously, monitoring respiratory status, especially if other injuries are suspected or if sedation is planned for reduction.
• Monitoring Point: Any change in neurovascular status (loss of pulse, increased pain, pallor, paresthesia, paralysis) is a medical emergency and must be reported instantly.

Nursing Procedure & Medication Flow Procedure: Immobilization of Suspected Hip Dislocation 1. Explain the procedure to the patient: "I'm going to support your leg to keep it from moving, which will help prevent more injury." 2. Using assistants if needed, gently slide rolled blankets or towels along the medial and lateral sides of the entire leg. 3. Secure the leg in its found position (flexed, adducted, internally rotated for posterior dislocation) using soft straps or tape over the blankets—never directly on the skin. 4. Reassess neurovascular status immediately after immobilization and document baseline.

Medication: IV Opioid (e.g., Morphine) Administration - Indication: Severe pain from musculoskeletal trauma. - Precautions: Assess baseline respiratory rate and level of consciousness (LOC). Have naloxone (Narcan) available. - Administration: Administer slowly IV push. Reassess pain and vital signs in 15-30 minutes.

A Word from Your Senior Nurse "In the chaos of the ED, it's easy to want to 'do something' quickly like give pain meds. But with orthopedic injuries, your first job is to be a stabilizer. That leg is a fragile, disconnected structure threatening nearby nerves and blood vessels. Securing it is the most therapeutic thing you can do in that first moment. Remember: First, do no further harm. This mindset of protecting the injury site applies to so much of nursing, from spinal precautions to stabilizing impaled objects. On the NCLEX, when you see 'priority' for trauma, always think: What will prevent the situation from getting worse right now?"